Illinois Bankers Association

Group Enrollment Form

Enrollment Form Tips
You will not be able to stop the enrollment process and complete it at a later date. Your enrollment must be completed in one sitting. You must have the following information ready to complete this form:

Employee Profile (Required)
Name, Address, City, State, Zip
Email and Phone
Date of Birth and SS Number
Employer Info: Name, Anniversary Date and Salary

Benefits
Beneficiary Name
Selected Health Plan

Spouse (if applicable)
Name, Date of Birth and SS Number

Children (if applicable)
Name, Date of Birth and SS Number


Employee Profile

Employee Full Name (Last, First, Middle)
Home Address
City, State, Zip
Email Address
Phone #
Gender
Date of Birth
Social Security Number
Married
Employer Name
Employment Anniversary
Annual Salary
Next (Please click the button only one time.)




I/we authorize any physician, medical practitioner, hospital, clinic or medical related facility, insurance or re-insuring company, having information available as to diagnose, treatment, and prognosis with respect to any physical, mental, drug or alcohol condition and/or treatment of me or my dependents to give/allow the Illinois Bankers Group Insurance Trust and the insurance companies underwriting the group benefits or their legal representative, any and all such information including but not limited to, Precertification of Hospital Admissions, Continued Stay Review, On-Sit-e Concurrent Review, Retrospective Review, Pre-Surgery Review, and patient visitation while I or my dependents are or have been a patient of a hospital, clinic, or medical related facility. 

Any information obtained will not be released to any person or organization exept to reinsuring companies, or other persons or organizations performing business or legal services in connection with my application, claim or as may be otherwise lawfully required or as I may further authorize.

I understand that this information will be used to determine appropriate and accurate medical charges.

I agree this this authorization shall be in force until released by me in writing.

I am aware that Pre-Admission Authorization and Pre-Surgery Review may be included in the medical plan and understand the procedures involved. I further understand that if I receive inpatient treatment without following the precertification procedure or surgical care without following the review requirements, I may be responsible for paying more of my hospital and/or surgical bill.