Health Insurance and Optional Enrollment Application
INSTRUCTIONS: ALABAMA RETIREE EMPLOYMENT VERIFICATION FORM (Form IB-16)
Alabama state employees who retire after September 30, 2005 are required to make use of any new employer's health benefit plan for primary coverage if the plan covers at least 50% of expenses. You can continue using state employees' insurance if necessary for supplemental and optional coverage. This form can be obtained from the website of the Alabama State Employees' Insurance Plan.
Alabama Retiree Employment Verification Form IB-16 Step 1: The first question on the reverse side of the letter you receive containing form IB-16 asks if you are currently employed. Check "Yes" or "No." If the latter, you do not need to complete the rest of the form. Sign, date and file the form.
Alabama Retiree Employment Verification Form IB-16 Step 2: On the first blank line of question 1, give your current employer's name.
Alabama Retiree Employment Verification Form IB-16 Step 3: On the second and third lines, give your current employer's address.
Alabama Retiree Employment Verification Form IB-16 Step 4: On the fourth blank line, provide your current employer's phone number including the area code.
Alabama Retiree Employment Verification Form IB-16 Step 5: On the fifth blank line, give the date on which you were hired.
Alabama Retiree Employment Verification Form IB-16 Step 6: Question 2 asks if your employer offers group health insurance. Check "Yes" or "No" as applicable. If the latter, you do not need to answer the remaining questions. Sign, date and file the form.
Alabama Retiree Employment Verification Form IB-16 Step 7: Question 3 asks if your employer contributes half or more of the cost of single health insurance coverage for employees. Check "Yes" or "No" as applicable. If the latter, you do not need to answer the last question. Sign, date and file the form.
Alabama Retiree Employment Verification Form IB-16 Step 8: Question 4 asks if you are eligible for your employer's group health insurance coverage. Check "Yes" or "No" as applicable. If "No," provide a written explanation.
Alabama Retiree Employment Verification Form IB-16 Step 9: Sign and date the form.
Alabama Retiree Employment Verification Form IB-16 Step 10: If your new employer ceases to pay at least 50% of the cost of single coverage, you may apply to re-enroll in the State Employees' Health Insurance Plan.
INSTRUCTIONS: ALABAMA RETIREE HEALTH INSURANCE ENROLLMENT FORM (Form IB04)
Alabama state employees who retire can enroll for health insurance through the state using a form IB04. This document can be obtained from the website maintained by the Alabama State Employees' Health Insurance Program.
Alabama Retiree Health Insurance Enrollment Form IB04 Step 1: Indicate with a check mark whether you are seeking basic SEHIP coverage, dental coverage only from Blue Cross, supplemental Blue Cross coverage, or optional Southland policies concerning vision, dental, cancer and hospital indemnity.
Alabama Retiree Health Insurance Enrollment Form IB04 Step 2: On the first line of the first table, enter your full name and sex.
Alabama Retiree Health Insurance Enrollment Form IB04 Step 3: On the second line, enter your Social Security number and date of birth.
Alabama Retiree Health Insurance Enrollment Form IB04 Step 4: On the third line, enter your street address.
Alabama Retiree Health Insurance Enrollment Form IB04 Step 5: On the fourth line, enter your city, county, state and zip code.
Alabama Retiree Health Insurance Enrollment Form IB04 Step 6: On the fifth line, enter your home and work telephone numbers.
Alabama Retiree Health Insurance Enrollment Form IB04 Step 7: If you are seeking dependent coverage, enter the date on which you request it to take effect.
'Alabama Retiree Health Insurance Enrollment Form IB04 Step 8: The next table requires you to list all dependents. The first line is for your husband or wife if applicable. Give their name in the first column, indicate whether they are your husband or wife with a check mark in the second column, give their date of birth in the third column, and enter their Social Security number in the fourth column.
Alabama Retiree Health Insurance Enrollment Form IB04 Step 9: The remaining lines of this table require the same information for any dependent children.
Alabama Retiree Health Insurance Enrollment Form IB04 Step 10: If you have additional group health insurance coverage, document it below. Indicate with a check mark whether this coverage is Medicare A, Medicare B or another insurance. If the latter, specify the coverage.
Alabama Retiree Health Insurance Enrollment Form IB04 Step 11: List the name of any health insurance and/or dental insurance company, the contract holder, the insurance policy and group numbers, and the providing employer's name. Sign and date the bottom of the page.
INSTRUCTIONS: ALABAMA RE-EMPLOYED STATE RETIREE HEALTH INSURANCE FORM (Form IB2)
Alabama state employees who retire and are then rehired by the state government can reacquire their state health insurance by filing a form IB2. This document can be obtained from the website of the Alabama State Employees' Insurance Board.
Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 1: Indicate with a check mark if you are filing for basic SEHIP coverage from BlueCross BlueShield or whether you are declining coverage.
Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 2: On the first blank line, enter your full name and sex.
Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 3: On the second blank line, enter your Social Security number, date of birth, and (if applicable) Medicare number.
Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 4: On the third blank line, enter your street address.
Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 5: On the fourth blank line, enter your city, state and zip code.
Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 6: On the fifth blank line, enter your home and work telephone numbers.
Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 7: In the next section, you must detail any dependents for whom you are seeking coverage. On the first line, enter the full name of your husband or wife in the first column, indicate which they are by circling the correct descriptor in the second column, enter their birth date in the third column, and enter their Social Security number in the fourth column.
Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 8: The remainder of the table for dependents requires you to document sons, daughters, stepsons and stepdaughters. Provide their names, indicate their relationship to you, and enter their dates of birth and Social Security numbers.
Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 9: If you wish to receive a non-tobacco user discount on your coverage, you must submit a separate Non-Tobacco User Discount Application.
Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 10: The bottom left corner of the form should be completed by your employer.
Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 11: Sign and date the bottom right corner of the form.
INSTRUCTIONS: ALABAMA RETIREE YEARS OF SERVICE VERIFICATION FORM (Form IB18)
Alabama retirees may be required to a complete a form IB18 to verify service credits they have received from the Retirement Systems of Alabama that were obtained from military service, service as a public education employee or employee of the Teachers' Retirement System, or service as an employee of a postsecondary institution eligible for Public Education Employees' Health Insurance Plan coverage. This document can be obtained from the website maintained by the Alabama State Employees' Insurance Board.
Alabama Retiree Years Of Service Verification Form IB18 Step 1: On the first blank line on the first page, your name will be entered.
Alabama Retiree Years Of Service Verification Form IB18 Step 2: Your street address will be on the second blank line.
Alabama Retiree Years Of Service Verification Form IB18 Step 3: Your city, state and zip code will be on the third blank line.
Alabama Retiree Years Of Service Verification Form IB18 Step 4: Your contract number will be on the fourth blank line.
Alabama Retiree Years Of Service Verification Form IB18 Step 5: Your retirement date will be on the fifth blank line.
Alabama Retiree Years Of Service Verification Form IB18 Step 6: On the second page, check the first box if your state retirement was a disability retirement. If so, you are not required to complete any other portion of the form other than providing your signature.
Alabama Retiree Years Of Service Verification Form IB18 Step 7: Check the second box if the years of service credited by the Retirement Systems of Alabama do not include credit for services other than the types of teaching, military or postsecondary institution employment described in the introductory paragraph of this article.
Alabama Retiree Years Of Service Verification Form IB18 Step 8: If your credited years of service are other than the types discussed in the introductory paragraph, you must document them in the next section. For each such employment, enter the name of your employer, the starting and ending dates of your employment and your total months employed in this capacity.
Alabama Retiree Years Of Service Verification Form IB18 Step 9: Enter your total months served in non-state years of service where indicated. Sign and date the bottom of the second page and enter your contract number.