Benefit Forms

Open Enrollment is now Closed.

For the various forms below you will need Adobe Acrobat Reader to view and print the forms. If you need help completing a form, bring the blank form into one of our local branch offices or call us directly.

Unsure if you qualify? View Benefits FAQS

Q: Who can I enroll? A: In addition to you, dependent coverage is offered in the medical, dental, and term life plans. Your eligible dependents are your lawful spouse and your unmarried children (who depend on you for support) from birth through age 18, through age 24 if a full-time student, or through any age if handicapped and unable to earn a living.

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Q: When does coverage begin and end?

A: Your coverage is effective on the first day of the month after you enroll, provided you are eligible.

View more Benefits FAQ's.

Benefits for New Employees

	Question and Answers and Print a Temporary Benefits Card 92 kb Print this form for your temporary insurance cards. It also contains information regarding the insurance provided and steps need to complete your enrollment and answers to common questions.

	Benefits Election Form 101 kb Complete this form to enroll in benefits or to make changes to your existing benefits. Fax completed form to Human Resources at 312-281-9084 or drop it off at your local branch.

	Benefits Brochure 394 kb The brochure covers the following areas medical, dental, short term disability, vision, hospital indemnity and term life with accidental death benefits.

	Benefits Summary 80 kb A brief summary of the coverages offered. For further information please view the entire form or contact Human Resources.

	Benefits Disclosure 38 kb Legal disclosures related to the available plans.

	Arizona Provider Directory 3,000 kb View a directory of Atena Providers in the state of Arizona.