Enrollment Forms

FOR NEW ILLINOIS GROUPS IN THE 1-50 MARKET
Employer Application
Employee Enrollment Form
Employee Enrollment Form – Spanish
Installation Census
Small Business Participation Form (for groups 10+ eligible)
Tax Documentation
Benefit Selection Form
ACH Form
Authorization Form

FOR NEW ILLINOIS GROUPS IN THE 51-100 MARKET
Employer Application
Employee Enrollment Form with No Medical History
Employee Enrollment Form with Medical History
Employee Enrollment Form with Medical History – Spanish
Fully Insured Member Level Census
HSA OptumHealthBank Enrollment Form

FOR EXISTING ILLINOIS GROUPS WITH NEW EMPLOYEES OR EMPLOYEE STATUS CHANGES
New Hire Employee Enrollment Form
New Hire Employee Enrollment Form – Spanish