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  Home > Employee Health & Welfare Benefits > Employee Benefit Trust > Downloadable Forms
   
 

Downloadable Forms

   
 

When mailing these completed forms back to us, please send them to:

Employee Benefit Services
1205 Windham Parkway
Romeoville, IL 60446-1679

 

We offer 2 ways in which to access the forms listed below.

 
To view these pdf's in your browser, click on the link of the form you wish to access below. You may need to download and install Adobe Reader. Adobe Reader is a free download.

Get Adobe Reader

 

OR
For those who would prefer to have these forms FAXED to them instead, we offer FaxBack, our Fax Information Service.

Simply call (toll-free) 1-888-470-INFO (4636) and follow the instructions.

 

 

FaxBack Document #

# of Pages
Attending Dentist's Statement pdf

Attending Dentist's Statement
(128 KB)


4050
2
CBEBT HIPAA Privacy Note pdf

CBEBT HIPAA Privacy Notice
(24 KB)

 

4070
6
Change of Address or Salary pdf

Change of Address or Salary
(6 KB)

 

4055
2
Change of Beneficiary Designation Form pdf

Change of Beneficiary Designation Form
(700 KB)

 

4045
4
Change Dependent Coverage pdf

Change of Dependent Coverage
(89 KB)

 

4040
2
CBEBT HIPAA Authorization Form pdf

Christian Brothers Employee Benefit Trust HIPAA Authorization Form
(48 KB)

 

4075
2
Dependent Eligibility Form pdf

Dependent Eligibility Form
(31 KB)

 

4065
2
Dependent Handicap Status Application Form pdf

Dependent Handicap Status Application Form
(32 KB)

 

7530
2
Diabetic Education Request w/Letterhead pdf

Diabetic Education Request w/Letterhead
(24 KB)

 

4090
1
Divorce Decree information pdf

Divorce Decree Information
(22 KB)

 

4080
1
Full Time Student-Dep Eligibility pdf

Full Time Student-Dep Eligibility
(56 KB)

 

4066
1
Late Entrant / Prior Waiver Form pdf

Late Entrant/ Prior Waiver Form
(172 KB)

 

4030
2
Life Insurance & Long Term Disability pdf

Life Insurance & Long Term Disability
(12 KB)

 

4095
2
Medco HIPAA Authorization Form pdf

Medco HIPAA Authorization Form
(60 KB)

 

4076
2
Other Coverage Information for Other Natural Parent pdf

Other Coverage Information for Other Natural Parent
(22 KB)

 

4086
1
Other Coverage Update pdf

Other Coverage Update
(21 KB)

 

4085
1
Probation Election Form pdf

Probation Election Form
(20 KB)

 

4005
2
Request for Change of Name pdf

Request for Change of Name
(44 KB)

 

4096

1
Request for Group Coverage Enrollment pdf

Request for Group Coverage Enrollment
(76 KB)

 

4010

7
Request for Waiver of Benefits

Request for Waiver of Benefits
(107 KB)

 

4060

3
Return from Leave of Absence pdf

Return from Leave of Absence
(73 KB)

 

4035

1
Special Enrollment Form pdf

Special Enrollment Form
(153 KB)


4020
4
Statement of Change of Active Employment pdf

Statement of Change of Active Employment
(158 KB)


4025
3

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