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Annual Certification of Private Insurance Coverage Form


pdf graphic Annual Certification of Private Insurance Coverage

Please view the Instructions below prior to using the above Annual Certification of Private Insurance Coverage Form.  The form is not to be retyped, scanned, or the wording altered in any way. Completed forms will not be accepted electronically via e-mail.

Instructions for form

This form has been designed to be used either manually or online. For future use, the form can be saved to your computer.

To fill out manually, open the form in Adobe Reader by clicking on the link and printing it out.  Once completed, the Annual Certification of Private Insurance Coverage Form should then be forwarded to the Administrative Office at the address indicated on the form, or faxed to 217-785-9114.

To fill out online, open the form In Adobe Reader by clicking on the link. Set the cursor to the Hand Tool, and use the tab key or mouse to navigate through the form.  Each fillable field is highlighted and has specific instructions for completion. Once completed, the Annual Certification of Private Insurance Coverage Form should then be forwarded to the Administrative Office at the address indicated on the form, or faxed to 217-785-9114.