Forms
Choose this option to access a variety of Enrollment Forms
For coverage enrollment, visit www.cityofchicagobenefits.org or call 1-877-299-5111
The following forms are for download only, and must be submitted in person or by mail:
- Blue Cross Blue Shield of Illinois Medical Claim Form
- Diabetes Management Program Enrollment Form
- Term Life Beneficiary Designation Form (MetLife)
- Creditable Coverage Notice
- HIPPA Authorization Form
- HIPAA Notice of Privacy Practices
- Civilian LTD Information
- Term Life Enrollment – Optional/Spouse/Child
- Fire LTD Enrollment
- Police LTD Enrollment
- FSA Claim Form – ConnectYourCare (as of January 1, 2019) – Medical Healthcare
- FSA Claim Form – ConnectYourCare (as of January 1, 2019) – Dependent Care
- Alternative Coverage Enrollment Form
- Public Safety Employee Benefits Act Application (PSEBA) Application
- Appeals Form