Get the free illinois health standard application small form

For the most current information concerning our state's health insurance rate and term policies, please use our new health insurance rate and term fact sheet. For more information, you can also contact the Illinois Department of Insurance's Office of Consumer Health Insurance toll-free actor by email at Application for Standard Health Plan (Self Employed) INSURER USE ONLY Policy/Group No. Section No. Effective Date New Hire Waiting Period For assistance in completing this application, please contact your employer or insurance agent. For information about your health insurance rights under state and federal law, and other resources, please contact the Illinois Department of Insurance's Office of Consumer Health Insurance toll-free actor by email at Request Premium Tax Credit Information. INSURER USE ONLY Policy/Group No. Section No. Effective Date (Effective Feb 2, 2013) New Hire Waiting Period Request Health Security Number (must be requested in writing and mailed to: Box 27000, Chicago, IL 60) For information about your health insurance rights under state and federal law, and other resources, please contact the Illinois Department of Insurance's Office of Consumer Health Insurance toll-free at. This standard application is intended to simplify your health insurance application process. For the most current information concerning our state's health insurance rate and term policies, please use our new health insurance rate and term fact sheet. For more information, you can also contact the Illinois Department of Insurance's Office of Consumer Health Insurance toll-free actor by email at (Effective May 19, 2017) Application for Standard Health Plan (Self-Employed), Standard Dental Plan — Self Employed Application for Standard Health Plan (Self-Employed), Standard Dental Plan — Self Employed Insurance Agency Request for Insurance Agency Statement.