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Online Form



You can apply for Blue Cross and Blue Shield of Illinois Medicare Supplement insurance 1 of 3 ways:


PLEASE NOTE: Before you apply you will want to read the Outline of Medicare Supplement Coverage for your plan. This will explain to you the benefits of your plan as well as the level at which each benefit is covered.


You can submit the application online by clicking the "Get Started" button below
Or print the application out and either mail or fax it to our office by clicking "Print the Application" below. You must print it out, sign it in ink and mail it to the address below. This application will be considered incomplete if it is not signed.



1. Click here to Complete Application on line



  • Have your Medicare card and Social Security card available to fill in the required information.
  • Send no money now! Complete the application then print, sign in ink and mail it to:

Health & Retirement Services of Illinois,
7101 N. Cicero Ave., Suite 202, Lincolnwood, IL. 60712


For coverage to go into effect, you must be age 65 or over, live in Illinois, and have Medicare Parts A and B.


All information will be kept confidential.



2.  Print the Application


  • Send no money now!

    Download and fill-out the application, sign in ink and mail it to

Health & Retirement Services of Illinois,
7101 N. Cicero Ave., Suite 202, Lincolnwood, IL. 60712



3. Call Toll-Free


Call 1-800-739-4700 for friendly customer assistance or request a free information kit.