Get Fy2014 Benefit Choice Election Form - State Of Illinois - Www2 Illinois

This guide provides a clear and comprehensive overview of the steps required to accurately complete the FY2014 BENEFIT CHOICE ELECTION FORM for the State of Illinois. Following these instructions will ensure that you effectively manage your benefits selections during the election period.

Follow the steps to complete your Benefit Choice Election Form.

1. Click ‘Get Form’ button to obtain the form and open it in your editing tool.
2. Complete Section A: Member Information. Provide your last name, first name, phone numbers (primary and alternate), email address, and Social Security Number.
3. In Section B, choose to opt out/waive coverage or opt in for health, dental, vision, and prescription plans. Mark your selection appropriately.
4. Move to Section C for Health Plan Elections. Specify the health plan you wish to choose (QCHP, OAP, or HMO) and provide required carrier details such as the carrier name and code.
5. If you chose an HMO, fill in the National Provider Identifier for your primary care physician.
6. Proceed to Section D for the Dental Plan Option. Indicate if you wish to drop or elect dental coverage according to your current enrollment status.
7. In Section E, address Member Optional Life Insurance. Indicate if you want to add, drop, or change your coverage levels including Accidental Death & Dismemberment (AD&D).
8. Complete Section F by providing information about any dependents you wish to add or modify coverage for, ensuring that necessary documentation is prepared.
9. Once all sections are completed, review your selections for accuracy, then sign and date the form.
10. Submit the completed form to your Group Insurance Representative no later than May 31, 2013. Ensure any additional documentation for dependents is submitted within the required timeframe.

Take the first step toward managing your benefits effectively by completing your Benefit Choice Election Form online today.