see all offices

RBG, PEORIA - FORMS
ASSURANT RELEASED DOWNLOAD
Employer Enrollment
AH LIST ENROLLMENT FORM 25+ EES
12/9/2014   Download
EMPLOYER APPLICATION- SELF FUNDED
10/10/2014   Download
EMPLOYER STOP LOSS APPLICATION- SELF FUNDED
11/8/2013   Download
SELF FUNDED ER GUIDE
2/25/2015   Download
Employee Enrollment
EE FULLY INSURED APP

Description:
Used for enrolling new group and new hires (pdf , 74k)
Version: U 4918

12/9/2014   Download
EE SELF FUNDED APP
3/9/2015   Download
IL SELF-FUNDED SUBMISSION KIT
12/29/2014   Download
IL UNIVERSAL APP ENGLISH
12/9/2014   Download
IL UNIVERSAL APP SPANISH
10/20/2014   Download
QUALIFYING LIFE EVENT FOR ENROLLMENT ON ER PLAN
2/25/2015   Download
TERMINATION NOTIFICATION
3/9/2015   Download
Administration
CENSUS TEMPLATE FOR QUOTING
2/12/2015   Download
FULLY INSURED AGENT GUIDE SMALL GROUPS
2/17/2015   Download
NEW- ASSURANT PRESCREEN COVER SHEET

Description:
To be used for all prescreen requests and sent to Christine and Dan. (doc , 35k)

5/6/2014   Download
RBG CHECKLIST
12/9/2014   Download
SELF FUNDED AGENT GUIDE FOR SMALL GROUPS
2/17/2015   Download
SELF FUNDED SUBMISSION CHECKLIST
9/12/2014   Download
SM GROUP COMMISSION AND PRODUCT SCHEDULE
2/17/2015   Download
Claims
MAIL ORDER HOME DELIVERY RX

Description:
For Mail Order Medications Home Delivery (pdf , 965k)
Version: HBLG2421

11/8/2013   Download
PRESCRIPTION REIMBURSEMENT FORM

Description:
reimbursement form (pdf , 621k)
Version: 30553 10/2012

10/31/2013   Download
Other
2015 PREFERRED DRUG LIST 2015
12/9/2014   Download
2015 STATE VARIATION FOR IL
2/25/2015   Download
COMPARISON CHART IL
3/27/2015   Download
PEDIATRIC DENTAL & VISION FLYER
2/25/2015   Download
PREVENTIVE/WELLNESS BENEFITS FLYER
2/25/2015   Download
SELF FUNDED BROCHURE
9/12/2014   Download
SELF FUNDED PLANS FLYER
4/29/2014   Download
SELF FUNDED PROGRAM 2014
10/22/2013   Download
SIMPLIFYING SELF FUNDING FLYER
4/29/2014   Download
TRANSITIONAL REINSURANCE PROGRAM 2015
2/25/2015   Download