Downloadable Forms for Individual & Family Markets

 

Here are some commonly used forms and documents for conducting business with Blue Cross and Blue Shield of Illinois (BCBSIL). The forms below are in portable document format (PDF). To view these files, you may need to install a PDF reader program. Most PDF readers are a free download. One option is Adobe® Reader®.

Current Individual Forms and Documents

Stock # / Date Enrollment/Change Forms Illinois Form #
852029.1023 2024 Individual Paper Application Checklist N/A
233178.1123 2024 Individual Health Plan Checklist (Spanish Version) N/A
32635.0124 2024 Health Application/Change in Coverage
Use this health application for 2024 plans effective January 1, 2024.
UN65-APP-Off-EX-2024
225331.0124 2024 Health Application/Change in Coverage (Spanish Version) UN65-APP-Off-EX-2024SP
225002.0124 2024 Dental Application/Change in Coverage
Use this dental application for 2024 plans effective January 1, 2024.
APP-DENT-IND-2024
225332.0124 2024 Dental Application/Change in Coverage (Spanish Version) APP-DENT-IND-2024SP
226771.1023 2024 Individual Paper Application Overflow Page
If you run out of room on the primary application for health plan coverage, use this form to add more dependents to your policy. Use this form for plans effective January 1, 2024.
UN65-APP-Off-EX-2024-O
226779.1123 2024 Individual Paper Application Overflow Page (Spanish Version) UN65-APP-Off-EX-2024SP-0
852029.1022 2023 Individual Paper Application Checklist N/A
233178.1122 2023 Individual Health Plan Checklist (Spanish Version) N/A
32635.1022 2023 Health Application/Change in Coverage
Use this health application for 2023 plans effective January 1, 2023.
UN65-APP-Off-EX-2023
225331.1122 2023 Health Application/Change in Coverage (Spanish Version) UN65-APP-Off-EX-2023SP
225002.1022 2023 Dental Application/Change in Coverage
Use this dental application for 2023 plans effective January 1, 2023.
APP-DENT-IND-2023
225332.1122 2023 Dental Application/Change in Coverage (Spanish Version) APP-DENT-IND-2023SP
226771.1022 2023 Individual Paper Application Overflow Page
If you run out of room on the primary application for health plan coverage, use this form to add more dependents to your policy. Use this form for plans effective January 1, 2023.
UN65-APP-Off-EX-2023-O
226779.1122 2023 Individual Paper Application Overflow Page (Spanish Version) UN65-APP-Off-EX-2023SP-0

 

Last Updated: Jan. 30, 2024