Groups 51-99

Illinois Applications

• IL Employee App 51+
• IL Employee App 51+ w. medical questions
• IL Employer App 51+

NW Indiana Applications

• NW IN Employee App 51+
• NW IN Employee App 51+ w. medical questions
• NW IN Employer App 51+

New Business

• 51-100 Checklist

Renewal

• IL 51-100 Renewal Checklist

• 1099 Form
• Billing & Collection Agreement - IL
• Commons Ownership Form
• Direct Debit Form
• FAM & OE Kit Request Form
• Product & Benefit Selection Form
• SSN Attestation Form

• Chicago & NW IN 51+ (Updated 3-1-2022)

• Prime New Business Enrollment (Excel)