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®.
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Downloadable Forms for Individual & Family Markets
Current Individual Forms and Documents
| Stock # / Date | Enrollment/Change Forms | Illinois Form # |
| 852029.1024 | 2025 Individual Paper Application Checklist | N/A |
| 233178.1124 | 2025 Individual Health Plan Checklist (Spanish Version) | N/A |
| 32635.1024 | 2025 Health Application/Change in Coverage Use this health application for 2025 plans effective January 1, 2025. |
UN65-APP-Off-EX-2025 |
| 225331.1124 | 2025 Health Application/Change in Coverage (Spanish Version) | UN65-APP-Off-EX-2025SP |
| 225002.1024 | 2025 Dental Application/Change in Coverage Use this dental application for 2025 plans effective January 1, 2025. |
APP-DENT-IND-2025 |
| 225332.1124 | 2024 Dental Application/Change in Coverage (Spanish Version) | APP-DENT-IND-2025SP |
| 226771.1024 | 2025 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, 2025. |
UN65-APP-Off-EX-2025-O |
| 226779.1124 | 2025 Individual Paper Application Overflow Page (Spanish Version) | UN65-APP-Off-EX-2025SP-0 |
| 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 |
Last Updated: Oct. 31, 2024