Application for benefits offerings - Coventry Health Care of Illinois 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Company Name, Group Number, and Effective Date in the designated fields. Ensure all information is accurate to avoid processing delays.
3. In the Eligibility Information section, specify the eligible employee categories by checking the appropriate boxes and providing necessary details such as hours worked.
4. Select your desired Product and Plan from the options provided. Make sure to indicate any additional riders you wish to include.
5. Complete the Dental Coverage section if applicable, ensuring that you provide prior coverage details and agree to contribution amounts.
6. Finally, review all entries for accuracy before signing at the bottom of the form. This ensures a smooth submission process.

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