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Online Agent Request Form

Please fill out the form below and a Blue Cross and Blue Shield of Illinois authorized agent will contact you within one to two business days. They will schedule an appointment at a time and location that is convenient for you. There is no cost or obligation for this service.

Which Medicare products are you interested in?

Medicare Supplement Insurance Plans

Medicare Advantage Prescription Drug Plans

Prescription Drug Plans

BlueCare Vision^SM

BlueCare Dental^SM

Appointment Type In Person Virtual

Appointment Notes/Comments

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Appointment Date and Time*

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Appointment Time Zone*

First Name*

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Last Name*

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Email Address*

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Date of Birth*

Please enter a valid date of birth MM/DD/YYYY

Address Line 1*

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Address Line 2 (Optional)

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City*

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State*

ZIP Code*

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County*

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Phone*

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You must be at least 18 years old to submit a request.

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By completing this form and providing your telephone number and/or email address, you agree an authorized representative or licensed agent from Blue Cross and Blue Shield of Illinois may call you on your landline (home phone), call or text your cellular phone, or email you to answer questions and provide additional information about Medicare products, health plan benefits and programs. Standard cellular phone and/or text message charges may apply from your wireless provider.

Coverage Plus Central provides information on coverage that may be of interest. Some products on Coverage Plus Central are not Blue Cross and Blue Shield products or services and are offered and underwritten by an insurer that is not affiliated with Blue Cross and Blue Shield of Illinois (BCBSIL). BCBSIL has contracted with Trionfo, an independent licensed insurance agency to provide this website.

The insurers offering the products featured on Coverage Plus Central are solely responsible for all financial and other obligations for those products. If you have a health insurance agent, you may also ask him or her for help with shopping for these products. A BCBSIL general agent/agent may receive a commission, or a fee may be paid to a subsidiary, from the sale of these products.