Get Opt Out & Opt In Election Certificate - Uic

The OPT OUT & OPT IN Election Certificate - Uic is a crucial document for employees of the State of Illinois wishing to manage their participation in health, dental, and vision coverage. This guide provides clear and detailed instructions for filling out the form online, ensuring that users understand each component and can complete the process smoothly.

Follow the steps to efficiently complete your Election Certificate.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section A, fill in your Member Name and Member SSN. Ensure accuracy as this information is essential for processing your application.
3. Read and understand the certification statements listed. By signing, you acknowledge your responsibilities and the impact of opting out or opting in.
4. Check the appropriate box under Proof of comprehensive coverage attached. This ensures that your opt-out request is valid.
5. Select your opt-out eligibility period by checking the appropriate box — Initial Enrollment, Benefit Choice, or Qualifying Change in Status.
6. If opting in, switch to Section B. Enter your Member Name and Member SSN again, following the same procedure as in Section A.
7. Confirm that you understand the conditions for opting back into the Program. Providing proof of a qualifying change in status is required unless it is during the Benefit Choice Period.
8. Submit the completed form along with necessary documentation to your Group Insurance Representative (GIR). Ensure that you also send any additional forms required for your application (CMS-310 or CMS-350).
9. After submission, keep a copy of your filled form for personal records. You may then choose to save changes, download, print, or share the form as needed.

Take action now and complete your OPT OUT & OPT IN Election Certificate online to manage your health coverage effectively.