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

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

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

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.

		# of Pages
	Attending Dentist's Statement (128 KB)	2
	CBEBT HIPAA Privacy Notice (24 KB)	6
	Change of Address or Salary (6 KB)	2
	Change of Beneficiary Designation Form (700 KB)	4
	Change of Dependent Coverage (89 KB)	2
	Christian Brothers Employee Benefit Trust HIPAA Authorization Form (48 KB)	2
	Dependent Eligibility Form (31 KB)	2
	Dependent Handicap Status Application Form (32 KB)	2
	Diabetic Education Request w/Letterhead (24 KB)	1
	Divorce Decree Information (22 KB)	1
	Full Time Student-Dep Eligibility (56 KB)	1
	Late Entrant/ Prior Waiver Form (172 KB)	2
	Life Insurance & Long Term Disability (12 KB)	2
	Medco HIPAA Authorization Form (60 KB)	2
	Other Coverage Information for Other Natural Parent (22 KB)	1
	Other Coverage Update (21 KB)	1
	Probation Election Form (20 KB)	2
	Request for Change of Name (44 KB)	1
	Request for Group Coverage Enrollment (76 KB)	7
	Request for Waiver of Benefits (107 KB)	3
	Return from Leave of Absence (73 KB)	1
	Special Enrollment Form (153 KB)	4
	Statement of Change of Active Employment (158 KB)	3

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