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Download enrollment materials, enrollment change forms, product brochures and detailed benefit summaries below. If you would like supplies mailed to you, please email enrollment@embenefits.com or phone 630-238-1900.

Enrollment Forms

FOR NEW ILLINOIS GROUPS IN THE 1-50 MARKET
Employer Application
Employee Enrollment Form
Installation Census
Small Business Participation Form (for groups 10+ eligible)
Tax Documentation
Benefit Selection Form
ACH Form
Authorization Form

FOR NEW ILLINOIS GROUPS IN THE 51-100 MARKET
Employer Application
Employee Enrollment Form with No Medical History
Employee Enrollment Form with Medical History
Fully Insured Member Level Census
HSA OptumHealthBank Enrollment Form

FOR EXISTING ILLINOIS GROUPS WITH NEW EMPLOYEES OR EMPLOYEE STATUS CHANGES
New Hire Employee Enrollment Form
New Hire Employee Enrollment Form

If you would like to receive carrier information for UnitedHealthcare, please visit our Broker Services page to request a kit.

REQUEST A BROKER KIT

UHC Product Grids

FOR GROUPS IN THE 1-50 MARKET
2022 UHC 1-50 (New Business) Illinois Product Package IL027
2022 UHC 1-50 (Renewals Only) Illinois Product Package IL028
2023 UHC 1-50 (New Business) Illinois Product Package IL029
2023 UHC 1-50 (Renewals Only) Illinois Product Package IL030
2024 UHC 1-50 Illinois Product Package IL031

FOR GROUPS IN THE 51-100 MARKET
2024 51+ Chicago & NW Indiana Plan Grid
Surest Illinois 51+ 2023 Product Grid
Surest Illinois 51+ 7/1/2024 Effective Date and Beyond
Effective 7/1/2023 - IL & NW IN–Plan 51+ Grid
Effective 7/1/2024 - IL & NW IN–Plan 51+ Grid

HOSPITAL/NETWORK LISTING and DESCRIPTION GUIDE
UHC Network Hospital Comparison Grid
UHC Network Description
UHC Fully Insured Plan Description Guide

CLAIM FORMS
Medical Claim Form
UHC Dental Claim Form
RX Claim Form

BROCHURES
UHC Rewards Employer Toolkit
GOA Chamber Flyer
HealthiestYou for Level Funded
UnitedHealthcare - Care Cash Flyer
UnitedHealthcare - Welcome to Wellness Flyer
UnitedHealthcare Real Appeal Flyer
UnitedHealthcare Rally Flyer
UnitedHealthcare Level Funded Illinois Mineral Flyer
UHC Mineral FAQ Flyer
UHC Mineral Offerings Flyer
Mineral Footprint Flyer
Surest Brochure
Surest Demo Guide
Surest Innovation Placemat
UHC Benefit Services
Charter Product Brochure
Charter Product FAQ
Nexus ACO Product Brochure
Specialty Benefits Quick Reference Guide
Ubundle vs Packaged Savings
Benefitter Brochure

Benefit Summaries

If the benefit summary you are looking for is not available here, please contact your EM Benefits Account Manager.

Search Results

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AE
AE-3Q AE-3S

AG
AG-87 AG-88 AG-89 AG-91 AG-92 AG-93 AG-94 AG-95 AG-96 AG-97 AG-98 AG-99 AG-9A AG-9B AG-9C AG-9D AG-9E AG-9F AG-9G AG-9H AG-9I AG-9J AG-9K AG-9L AG-9M AG-9N AG-9O AG-9P AG-9Q AG-9R AG-9S AG-9T AG-9U AG-9V AG-9W AG-9X AG-9Y AG-9Z AG-U4 AG-U5 AG-U6

AH
AH-A1 AH-A2 AH-A3 AH-A4 AH-A5 AH-A6 AH-A7 AH-A8 AH-A9 AH-AA AH-AB AH-AC AH-AD AH-AE AH-AF AH-AG AH-AH AH-AI AH-AJ AH-AK AH-AL AH-AM AH-AN AH-AO AH-AP AH-AQ AH-AT AH-AU AH-AV AH-AW AH-AX AH-AY AH-AZ AH-B1 AH-B2 AH-B3 AH-B4 AH-B5 AH-B6 AH-B7 AH-B8 AH-B9 AH-BA AH-BB AH-BC AH-BD AH-BE AH-BF AH-BG AH-BH AH-BI AH-BJ AH-BK AH-BL AH-BM AH-BN AH-BO AH-BP AH-BQ AH-BR AH-BS AH-BT AH-BU AH-BV AH-BW AH-BX AH-BY AH-BZ AH-CA AH-CB AH-CC AH-CD AH-CE AH-CF AH-CG AH-CH AH-CI AH-CJ AH-CK AH-CL AH-CM AH-AR AH-AS

AK
AK-TB AK-TC AK-TD AK-TE AK-TF AK-TG AK-TH AK-TI AK-TJ AK-TK AK-UG AK-UH AK-UI AK-UJ AK-UK AK-UL AK-UM AK-UN AK-UO AK-UP AK-UQ AK-UR AK-US AK-UT AK-UU AK-UV AK-UW AK-UX

AL
AL-14 AL-15 AL-1O AL-1T AL-1V AL-2D AL-2S

AM
AM-2V AM-2W AM-2X AM-2Y AM-2Z AM-21 AM-22 AM-23 AM-24 AM-25 AM-26 AM-27 AM-28 AM-29 AM-3A AM-3B AM-3C AM-3D AM-3E AM-3F AM-3G AM-3H AM-3I AM-3J AM-3K AM-3L AM-3N AM-3O

AN
AN-CN AN-CO AN-CP AN-CQ AN-CR AN-CS AN-EZ AN-E1 AN-E2 AN-E3 AN-E4 AN-E5 AN-K3

AU
AU-G1 AU-G2 AU-G3 AU-G4 AU-G5 AU-G6 AU-G7 AU-G8 AU-G9 AU-GP AU-GQ AU-GR AU-GS AU-GT AU-GU AU-GV AU-GW AU-GX AU-GY AU-GZ AU-H1 AU-H2 AU-H3 AU-H4 AU-HA AU-HB AU-HC AU-HD AU-HE AU-HF AU-HG AU-HH AU-HI AU-HJ AU-HK AU-HL AU-HM AU-HN AU-HO AU-HP AU-HQ AU-HR AU-HS AU-HT AU-HU AU-HV AU-HW AU-HX AU-HY AU-HZ

AX
AX-L1 AX-L2 AX-L3 AX-L4 AX-LO AX-LP AX-LQ AX-LR AX-LS AX-LT AX-LU AX-LV AX-LW AX-LX AX-LY AX-LZ AX-T1 AX-T2 AX-T3 AX-T4 AX-T5 AX-T6 AX-T7 AX-T8 AX-T9 AX-TY AX-TZ AX-UA AX-ZC AX-ZD AX-ZE AX-ZF AX-ZC AX-ZD AX-ZE AX-ZF

BC
BC-8P BC-8Q BC-8R BC-8S BC-8T BC-8U BC-8V BC-8W

BD
BD-C5 BD-DM BD-P6 BD-TI BD-TJ BD-TK BD-TL BD-DJ BD-DL BD-DN BD-DP BD-DI BD-DK BD-DO BD-QD BD-AN BD-AO BD-AP BD-AQ BD-AR BD-C4 BD-C6 BD-C7 BD-C8 BD-CX BD-P2 BD-P4 BD-P8 BD-PY BD-PZ BD-QA BD-QB BD-QF BD-QI BD-QK BD-QM BD-QQ BD-QR BD-QS BD-QT BD-QU BD-QV BD-R2 BD-R3 BD-R4 BD-R5 BD-R6 BD-R7 BD-RQ BD-RR BD-RS BD-RT BD-RU BD-RV BD-RW BD-RX BD-RY BD-RZ BD-SH BD-SJ BD-SK BD-SL BD-SM BD-SN BD-SO BD-SP BD-SQ BD-SR BD-TC BD-TD BD-TE BD-TM BD-TN BD-TO BD-TP BD-TQ BD-TR BD-TS BD-TT BD-TU BD-AS BD-AT BD-AU BD-AV BD-AW BD-C2 BD-C3 BD-C9 BD-CY BD-CZ BD-DA BD-P3 BD-P5 BD-P7 BD-P9 BD-Q3 BD-QC BD-QE BD-QG BD-QH BD-QJ BD-QL BD-QN BD-QW BD-QX BD-QY BD-QZ BD-R8 BD-R9 BD-S2 BD-S3 BD-S4 BD-S5 BD-S6 BD-S7 BD-S8 BD-S9 BD-SA BD-SC BD-SD BD-SE BD-SF BD-SG BD-SS BD-ST BD-SU BD-SV BD-SW BD-SX BD-SY BD-SZ BD-T2 BD-T3 BD-T4 BD-T5 BD-TA BD-TF BD-TG BD-TH BD-TV BD-TW BD-TX BD-TY BD-TZ BD-QO BD-QP

BF
BF-D2 BF-EA BF-D3 BF-D4 BF-D5 BF-D6 BF-D7 BF-D8 BF-DM BF-DN BF-DO BF-DP BF-DQ BF-DR BF-DS BF-DT BF-DU BF-DV BF-DW BF-DX BF-DY BF-DZ BF-D9 BF-EB BF-EC BF-ED BF-EE BF-C2 BF-C3 BF-C4 BF-C5 BF-C6 BF-C7 BF-C8 BF-C9 BF-CT BF-CU BF-CV BF-CW BF-CX BF-CY BF-CZ BF-DA BF-DB BF-DC BF-DD BF-DE BF-DF BF-DG BF-DH BF-DI BF-DJ BF-DK BF-DL

BH
BH-O2 BH-O3 BH-O4 BH-O5 BH-O6 BH-O7 BH-O8 BH-O9 BH-OZ BH-P2 BH-P3 BH-P4 BH-P5 BH-P6 BH-P7 BH-P8 BH-P9 BH-P9 BH-PB BH-PC BH-PD BH-PE BH-PF BH-PG BH-PH BH-PI BH-PJ BH-PK BH-PL BH-PM BH-PN BH-PO BH-PP BH-PQ BH-PR BH-PS BH-PT BH-PV BH-PW BH-PX BH-PZ BH-QA BH-QB BH-QC BH-QD BH-QE BH-QF BH-QG

BJ
BJ-XE BJ-XF BJ-XG BJ-XH BJ-XI

BK
BK-TO

BO
BO-EF BO-EG BO-EH BO-EI BO-EJ BO-EK BO-EL BO-EM BO-EN BO-EO BO-EP BO-EQ BO-ER BO-ES BO-ET BO-EU

BR
BR-N6 BR-N7 BR-N8 BR-N9 BR-O2 BR-O3 BR-O4 BR-O5 BR-O6 BR-O7 BR-O8 BR-O9 BR-OA BR-OB BR-OC BR-OD BR-OE BR-OF BR-OG BR-OH BR-OI BR-OJ BR-OK BR-OL BR-OM BR-ON BR-OO BR-OP BR-OQ BR-OR BR-OS BR-OT BR-OU BR-OV BR-OW BR-OX BR-OY BR-OZ BR-PA BR-PB BR-PC BR-PD BR-PE BR-PF BR-PG BR-PH BR-PI BR-PJ BR-PK BR-PL BR-PM BR-PN BR-PO BR-YG BR-YH BR-YI BR-YJ BR-YK BR-YL BR-YM BR-YN BR-YO BR-YP BR-YQ BR-YR BR-YS

BS
BS-4U BS-4V BS-4W BS-4X BS-4Y BS-4Z BS-5A BS-5B BS-42 BS-43 BS-44 BS-45 BS-46 BS-47 BS-48

BT
BT-I6 BT-I7 BT-I8 BT-I9 BT-JA BT-JB BT-JC BT-JD BT-JE BT-JF BT-JG BT-JH BT-JI BT-JJ BT-JK BT-JL BT-JM BT-JN BT-JO BT-JP BT-JQ BT-JR BT-JS BT-JT BT-JU BT-JV BT-JW BT-JX BT-X4 BT-X7 BT-X8 BT-XL BT-XM BT-XN BT-XO BT-XP BT-XQ BT-XR BT-XS BT-XT BT-XU BT-XV BT-XW BT-XX BT-XY BT-XZ

CC
CC-N2 CC-N3 CC-N4 CC-N5 CC-N6 CC-N7 CC-N8 CC-N9 CC-NO CC-NP CC-NQ CC-NR CC-NS CC-NT CC-NU CC-NV CC-NW CC-NX CC-NY CC-NZ CC-O2 CC-O3 CC-O4 CC-O5 CC-O6 CC-O7 CC-O8 CC-O9 CC-OA CC-OB CC-OG CC-OH CC-OI CC-OJ CC-OK CC-OL CC-OM CC-OO CC-OP CC-OQ CC-OR CC-OS CC-OT CC-OU CC-OV CC-OW CC-OX CC-OY CC-OZ CC-P2 CC-P3 CC-P4 CC-P5 CC-P6 CC-P7 CC-P8 CC-P9 CC-PA CC-PB CC-PC CC-PD CC-PE CC-PF CC-PG CC-PH CC-PI CC-PJ CC-PL CC-PK CC-PM CC-PN CC-PO CC-PP CC-PQ CC-PR CC-PS CC-PT CC-PU CC-PV CC-PW CC-PX CC-PY CC-PZ CC-QA CC-QB CC-QC CC-QD CC-QE CC-QF CC-QG CC-QH CC-QI CC-QJ

CD
CD-YO

CF
CF-1V CF-1W CF-1X CF-1Y CF-1Z CF-12 CF-14 CF-15 CF-16 CF-17 CF-18 CF-19 CF-2A CF-2B CF-2C CF-2D CF-2E CF-2F CF-2G CF-2H CF-2I CF-MH CF-MI CF-MJ CF-MK CF-ML CF-MM CF-MN CF-MO CF-MP CF-MQ

CG
CG-AA CG-AB CG-AC CG-AD CG-AE CG-AF CG-AG CG-AH CG-AI CG-AJ CG-AK CG-AL CG-AM CG-AN CG-AO CG-AP CG-AQ CG-AR

CN
CN-H2 CN-H3 CN-H4 CN-H5 CN-H6 CN-H7 CN-H8 CN-H9 CN-HD CN-HE CN-HF CN-HG CN-HH CN-HI CN-HJ CN-HK CN-HM CN-HN CN-HL

CO
CO-FP CO-FQ CO-FR CO-FS CO-FT CO-FU

CV
CV-E2 CV-E3 CV-E4 CV-E5 CV-E6 CV-E7 CV-E8 CV-EI CV-EK CV-EL CV-EN CV-EP CV-EQ CV-ER CV-ES CV-ET CV-EU CV-EV CV-EW CV-EX CV-EY CV-EZ CV-F2 CV-F4 CV-F5 CV-F6 CV-F7 CV-FD CV-FE CV-FF CV-FG CV-FH CV-FI CV-FJ CV-FK CV-FL CV-FM CV-FN CV-FO CV-FP CV-FQ CV-FR CV-FS CV-FT CV-FU CV-FV CV-FW CV-FX CV-FY CV-FZ CV-G2 CV-G5 CV-G6 CV-G8 CV-G9 CV-GA CV-GB CV-GC CV-GD CV-GE CV-GF CV-GG CV-GH CV-GI CV-GJ CV-GK CV-GL CV-GM CV-GN CV-GO CV-GP CV-GQ CV-GR CV-GU CV-GV CV-GX CV-GZ CV-H2 CV-H3 CV-H4 CV-H5 CV-H6 CV-H7 CV-HC CV-HD CV-HF CV-HH CV-HL CV-HP CV-HQ CV-HR CV-HS CV-HT CV-HU CV-HV CV-HW CV-HY CV-HZ CV-IE CV-IF CV-IG CV-IH CV-II CV-IJ CV-K2 CV-KN CV-KO CV-KP CV-KZ CV-L2 CV-L3 CV-L4 CV-LD CV-LE CV-LF CV-LG CV-LH CV-LL CV-LM CV-LP CV-LQ CV-LR CV-LS CV-LT CV-LU CV-LX CV-LY CV-LZ

DG
DG-22 DG-23 DG-24 DG-2C DG-2D DG-2E DG-2F DG-2G DG-2H DG-2I DG-2J DG-2K DG-2L DG-2M DG-2N DG-2O DG-2P DG-2Q DG-2R DG-2S DG-2T DG-2U DG-2V DG-2W DG-2X DG-2Y DG-2Z

DH
DH-I2 DH-I3 DH-I4 DH-I5 DH-I6 DH-I7 DH-I8 DH-I9 DH-IF DH-IG DH-IH DH-II DH-IJ DH-IK DH-IL DH-IM DH-IN DH-IO DH-IP DH-IQ DH-IR DH-IS DH-IT DH-IU DH-IV DH-IW DH-IX DH-IY DH-IZ DH-J2 DH-J3 DH-J4 DH-J5 DH-J6 DH-J7 DH-J8 DH-J9 DH-JA DH-JB DH-JC DH-JD DH-JE DH-JF DH-JG DH-JH DH-JI DH-JJ DH-JK DH-JL DH-JM DH-JN DH-JO DH-JP DH-JQ DH-JR DH-JS DH-JT DH-JU DH-JV DH-JW DH-JX DH-JY DH-JZ DH-KA DH-KB DH-KC DH-KD DH-KE DH-KF DH-KG DH-KH DH-KI DH-KJ DH-KK DH-KL DH-KM DH-KN DH-KO DH-KP DH-KQ DH-KR DH-KS DH-KT DH-KU DH-KV DH-N2 DH-N3 DH-N4 DH-N5 DH-N6 DH-N7 DH-N8 DH-N9 DH-OA DH-OB DH-OC DH-OD DH-OE DH-OF DH-OG DH-OH DH-OI DH-OJ DH-OK DH-OL DH-OM DH-ON DH-OO DH-OP DH-OQ DH-OR DH-OS DH-OT

DJ
DJ-15 DJ-62 DJ-63 DJ-6P DJ-6Q DJ-6Y DJ-6Z DJ-J2

DS
DS-IS

DX
DX22-E82S DX23-E82S DX24-E82S DX25-E82S DX26-E82S DX27-E82S DX28-E82S DX29-E82S DX32-E82S DX35-E82S DX38-E82S DX39-E82S DX33-K63S DX34-K63S DX36-K63S DX37-K63S DX2S-E82S DX2T-E82S DX2U-E82S DX2V-E82S DX2W-E82S DX2X-E82S DX2Y-E82S DX2Z-E82S DX3A-E82S DX3B-E82S DX3C-E82S DX3D-E82S DX3E-E82S DX3F-E82S DX3G-E82S DX3H-E82S DX3I-E82S DX3J-E82S DX3K-E82S DX3L-E82S DX3M-E82S DX3N-E82S DX3O-E82S DX3P-E82S DX3Q-E82S DX3R-E82S DX3S-E82S DX3T-E82S DX3U-E82S DX3V-E82S DX3W-E82S DX3X-E82S DX3Y-E82S DX3Z-E82S DX4A-E82S DX4B-E82S DX4C-E82S DX4D-E82S DX4E-E82S DX4F-E82S DX4G-E82S DX4H-E82S DX4I-E82S DX4J-E82S DX4K-E82S DX4L-E82S DX4M-E82S DX4N-E82S DX4O-E82S DX4P-E82S DX4Q-E82S DX4R-E82S DX4S-E82S DX4T-E82S DX4U-E82S DX4V-E82S DX4W-E82S DX4X-E82S

DY
DYG2-K35S DYG3-K35S DYG4-K35S DYG5-K35S DYGG-K35S DYGH-K35S DYGI-K35S DYGJ-K35S DYGK-K35S DYGL-K35S DYGM-K35S DYGN-K35S DYGO-K35S DYGP-K35S DYGQ-K35S DYGR-K35S DYGS-K35S DYGT-K35S DYGU-K35S DYGZ-K35S DYU2-K35S DYU3-K35S DYU4-K35S DYU5-K35S DYU6-K35S DYU7-K35S DYU8-K35S DYU9-K35S DYUR-K35S DYUS-K35S DYUT-K35S DYUU-K35S DYUV-K35S DYUW-K35S DYUX-K35S DYUY-K35S DYUZ-K35S DYV2-K35S DYV3-K35S DYV4-K35S DYVA-K35S DYVB-K35S DYVC-K35S DYVD-K35S DYVE-K35S DYVF-K35S DYVG-K35S DYVH-K35S DYVI-K35S DYVJ-K35S DYVK-K35S DYVL-K35S DYVM-K35S DYVN-K35S DYVO-K35S DYVP-K35S DYVQ-K35S DYVR-K35S DYVS-K35S DYVT-K35S DYVU-K35S DYVV-K35S DYVW-K35S DYVX-K35S DYVY-K35S DYVZ-K35S

RX
2V 2V HSA 3B 51 454 455 751 C24 C25 C26 C27 DS EU F5 G4 H9 I1 IU KU 0H oI G76Y G79Y

VISION
Illinois Vision Plan Grid Illinois Vision Plan SF006 Illinois Vision Plan SF008 Illinois Vision Plan SF010 Illinois Vision Plan SF012 Illinois Vision Plan S1006 Illinois Vision Plan S1008 Illinois Vision Plan S1010 Illinois Vision Plan S1012

DENTAL
Illinois Dental Plan Enhancements Overview Illinois Dental P1211 Options PPO Illinois Dental P1266 Options PPO Illinois Dental A7976 Options PPO Illinois Dental A7981 Options PPO

SUREST
A 2500 A 3000 A 4000 A 1500 A 2000 B 4000 B 5000 C 5000 C 6000 D 5500 D 6500 E 6000 E 7000 F 7000 F 8000 F 8500 F 9000