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Participant Center Forms and Notices for All Participant Groups
HIPAA Privacy Notice
This HIPAA Privacy Notice provides information regarding the Protection of your Health Information and your rights with respect to your privacy.

Authorization to Release Protected Health Information (PHI) Form
This form should be used if you would like another person or entity other than yourself to receive your protected health information.

Change of Address Form
This form should be used to notify EIT of your new address. You can also register for an EIT Online Account to make future address changes.

CVS Drug Lists Dependent Information Request Form
Federal Law now requires that health plans report Social Security Numbers (SSNs) for covered dependents. Please utilize this form to provide SSNs for all dependents.

Disability application instructions and form to apply for Disability Benefits.
(Disability Benefits do not apply to Participants of the Participatory Plan or who are currently covered under COBRA) Group Life Beneficiary Designation Form
This is a form to fill out and mail to us if you would like to designate a beneficiary or update beneficiary information.

Medicare FAQ
Frequently Asked Questions about Medicare Benefits.

Registering Your EIT Online Account
This is guide will walk you through creating your online account where you can view work history, pension history and make changes to your contact information.

(you must have a valid address on file with EIT to register, the Change of Address form above will allow you to update your address prior to registering)

Request for Disabled Dependent Coverage
Request for Disabled Dependent Coverage Form.

Subrogation Questionnaire

Workers’ Compensation Disability Statement
Effective November 1, 2015, if you are injured at work, you must file a completed Workers’ Compensation Disability Statement within 90 days of the later of either the last day you worked contributed hours or the date of your injury. Claims filed after 90 days will not be accepted and no Disability Hours will be credited to maintain your health insurance.

Useful Tax Forms
  • IL W-4  (Illinois Employee Withholding)
  • IL W-5-NR  (Illinois Nonresidence Statement)
  • IRS W-4  (Federal Employee Withholding)
  • IRS W-4P  (Federal Pension Withholding)
  • IRS W-4S  (Federal Sick Pay Withholding)
  • IRS W-9  (Request for Taxpayer Identification)

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