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Health Insurance Enrollment IB02 – New employees only

Health Insurance Enrollment IB02 - New employees only

 

INSTRUCTIONS: ALABAMA HEALTH INSURANCE ENROLLMENT FORM (Form IB02)

 

 

Alabama state employees file for health insurance for themselves and qualifying dependents using a form IB02. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

 

Alabama Health Insurance Enrollment Form IB02 Step 1: Indicate with a check mark if you are filing for basic medical coverage, secondary supplemental coverage, optional policies for vision, dental and hospital indemnity, or if you are declining coverage.

 

Alabama Health Insurance Enrollment Form IB02 Step 2: Enter your full name and sex.

 

Alabama Health Insurance Enrollment Form IB02 Step 3: Enter your Social Security number and date of birth.

 

Alabama Health Insurance Enrollment Form IB02 Step 4: Enter your street address, city, state and zip code.

 

Alabama Health Insurance Enrollment Form IB02 Step 5: Enter your home and work telephone numbers, as well as your email address.

 

Alabama Health Insurance Enrollment Form IB02 Step 6: Enter the date on which you are requesting that coverage take effect for dependents.

 

Alabama Health Insurance Enrollment Form IB02 Step 7: The next section requires you to list all dependents you are seeking coverage for. Enter their name, indicate their relationship to you with a check mark, and provide their date of birth and Social Security number. Note that you cannot obtain coverage for a divorced or common-law spouse.

 

Alabama Health Insurance Enrollment Form IB02 Step 8: If you have additional group health insurance, indicate whether it has a spousal-carve out.

 

Alabama Health Insurance Enrollment Form IB02 Step 9: Enter the name of the company providing this insurance.

 

Alabama Health Insurance Enrollment Form IB02 Step 10: Enter the name of the contract holder and the policy number.

 

Alabama Health Insurance Enrollment Form IB02 Step 11: Enter the group number and the name of the employer providing this insurance.

 

Alabama Health Insurance Enrollment Form IB02 Step 12: Indicate with a check mark whether this plan includes dental coverage. If so, you must give the name of the dental insurance company, the policy and group number, and the name of the providing employer.

 

Alabama Health Insurance Enrollment Form IB02 Step 13: The section at the bottom left should be completed by your current employer.

 

Alabama Health Insurance Enrollment Form IB02 Step 14: Sign and date the form at the bottom right.

 

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Provider Screening Form IB13

Provider Screening Form IB13

 

INSTRUCTIONS: ALABAMA PROVIDER SCREENING FORM (Form IB13)

 

 

Alabama state employees who choose not to participate in Worksite Wellness screenings may instead submit health screening results through a healthcare provider. This is done using a form IB13. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

 

Alabama Provider Screening Form IB13 Step 1: Section 1 should be completed by the employee. In the first blank box, enter your name.

 

Alabama Provider Screening Form IB13 Step 2: In the second blank box, enter the screening date.

 

Alabama Provider Screening Form IB13 Step 3: In the third blank box, indicate whether you are male or female with a check mark.

 

Alabama Provider Screening Form IB13 Step 4: In the fourth blank box, enter your age.

 

Alabama Provider Screening Form IB13 Step 5: In the fifth blank box, enter your contract number.

 

Alabama Provider Screening Form IB13 Step 6: In the sixth blank box, enter your Social Security number.

 

Alabama Provider Screening Form IB13 Step 7: In the seventh blank box, enter your date of birth.

 

Alabama Provider Screening Form IB13 Step 8: In the eighth blank box, enter your daytime telephone number.

 

Alabama Provider Screening Form IB13 Step 9: Indicate your race or ethnicity with a check mark.

 

Alabama Provider Screening Form IB13 Step 10: Indicate with a check mark whether you have or have been told you have high cholesterol, high blood pressure or diabetes.

 

Alabama Provider Screening Form IB13 Step 11: Indicate with a check mark whether you take any medication for the conditions listed in step 10.

 

Alabama Provider Screening Form IB13 Step 12: The second section should be completed by your health care provider. They will detail your blood pressure, total cholesterol, HDL and LDL cholesterol, triglycerides, blood glucose, height, weight, body mass index, waist measurement, and waist/height ratio.

 

Alabama Provider Screening Form IB13 Step 13: On the next blank line, the provider should print their name.

 

Alabama Provider Screening Form IB13 Step 14: On the next blank line, the provider should enter their signature.

 

Alabama Provider Screening Form IB13 Step 15: On the next blank line, the provider should enter their address.

 

Alabama Provider Screening Form IB13 Step 16: The completed form should be returned to the State Employees' Insurance Board at the address given at the bottom of the page.

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Wellness Discount Certification Form IB07

Wellness Discount Certification Form IB07

 

INSTRUCTIONS: ALABAMA WELLNESS DISCOUNT CERTIFICATION FORM (Form IB07)

 

 

Alabama state employees who have participated in a worksite wellness screening and have since taken correctly documented steps to control identified health risks may apply for a wellness premium discount on their health insurance coverage by filing a form IB07. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

 

Alabama Wellness Discount Certification Form IB07 Step 1: In the first blank box, enter the member name.

 

Alabama Wellness Discount Certification Form IB07 Step 2: In the second blank box, indicate with a check mark whether you are male or female.

 

Alabama Wellness Discount Certification Form IB07 Step 3: In the third blank box, enter your age.

 

Alabama Wellness Discount Certification Form IB07 Step 4: In the fourth blank box, enter your contract number.

 

Alabama Wellness Discount Certification Form IB07 Step 5: In the fifth blank box, enter your Social Security number.

 

Alabama Wellness Discount Certification Form IB07 Step 6: In the sixth blank box, enter your date of birth.

 

Alabama Wellness Discount Certification Form IB07 Step 7: In the seventh blank box, enter your daytime telephone number, including the area code.

 

Alabama Wellness Discount Certification Form IB07 Step 8: Check the first box if you were counseled by a health provider. You must attach either a wellness program office visit referral or a completed provider screening form documenting results. Indicate which with a check mark.

 

Alabama Wellness Discount Certification Form IB07 Step 9: Check the fourth box if you participated in a Physician Supervised Weight Management program. Enter the name and phone number of the program and the dates on which you attended.

 

Alabama Wellness Discount Certification Form IB07 Step 10: Check the fifth box if you participated in a SEIB Fitness Center's wellness program. Enter the name and phone number of the program, the dates you attended and a program description.

 

Alabama Wellness Discount Certification Form IB07 Step 11: Check the sixth box if you self-managed your health risks. You must attach valid proof.

 

Alabama Wellness Discount Certification Form IB07 Step 12: You must submit this form to the Alabama State Employees' Insurance Board no later than November 30th. Incomplete forms will not be processed and will be returned. Mail the form to the address given at the bottom of the page.

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COBRA Form 11 IB11

COBRA Form 11 IB11

 

INSTRUCTIONS: ALABAMA COBRA EMPLOYER NOTICE MEMO (Form IB11)

 

 

When an Alabama state employee enrolled in the state's SEHIP retirement plan is terminated, dies, has a reduction in hours or becomes eligible for Medicare, their employer must file a form IB11. This form is available on the website maintained by the Alabama State Employees' Insurance Board. Note that instead of filing this memo, you may choose to file a form 11 instead. Further assistance may be obtained by calling the telephone number given at the bottom of the page.

 

Alabama COBRA Employer Notice Memo IB11 Step 1: On the first blank line, enter the name of the employee.

 

Alabama COBRA Employer Notice Memo IB11 Step 2: On the second blank line, enter the Social Security number of the employee.

 

Alabama COBRA Employer Notice Memo IB11 Step 3: On the third blank line, enter the number and street or P.O. box of the employee.

 

Alabama COBRA Employer Notice Memo IB11 Step 4: On the fourth blank line, enter the city, state and zip code of the employee.

 

Alabama COBRA Employer Notice Memo IB11 Step 5: On the fifth blank line, enter the name of the employer.

 

Alabama COBRA Employer Notice Memo IB11 Step 6: If the employee has been terminated for any reason other than gross misconduct, check line 1. Enter the date of their termination.

 

Alabama COBRA Employer Notice Memo IB11 Step 7: If the employee has had their hours reduced, including a reduction in leave without pay, check line 2. Enter the date on which the reduction took effect.

 

Alabama COBRA Employer Notice Memo IB11 Step 8: If the employee has died, check line 3. Enter the date of death.

 

Alabama COBRA Employer Notice Memo IB11 Step 9: If the employee has become eligible for Medicare, check line 4. Enter the date on which they become eligible. Note that this will only affect medical coverage. Dental, prescription or vision care coverage will remain in effect.

 

Alabama COBRA Employer Notice Memo IB11 Step 10: On the next blank line, enter the date.

 

Alabama COBRA Employer Notice Memo IB11 Step 11: On the next blank line, the employer should enter their name.

 

Alabama COBRA Employer Notice Memo IB11 Step 12: Mail the form to the address given at the bottom of the page. You may also fax it to the number given. 

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Plan Change Form State Employee IB14

Plan Change Form State Employee IB14

 

INSTRUCTIONS: ALABAMA STATE EMPLOYEE PLAN CHANGE FORM (Form IB14)

 

 

Alabama state employees who wish to change their health insurance coverage do so by filing a form IB14. This form can be obtained from the website of the Alabama State Employees' Insurance Board.

 

Alabama State Employee Plan Change Form IB14 Step 1: At the top of the form, check the box next to the type of coverage you are seeking to obtain, or indicate if you are declining coverage.

 

Alabama State Employee Plan Change Form IB14 Step 2: On the first line enter your name, sex and the date on which coverage took effect.

 

Alabama State Employee Plan Change Form IB14 Step 3: On the second line enter your contact telephone number and date of birth.

 

Alabama State Employee Plan Change Form IB14 Step 4: On the third line enter your street address.

 

Alabama State Employee Plan Change Form IB14 Step 5: On the fourth line enter your city, state and zip code.

 

Alabama State Employee Plan Change Form IB14 Step 6: On the fifth line enter your home and work telephone numbers, as well as your email address.

 

Alabama State Employee Plan Change Form IB14 Step 7: The next four blank lines are provided to document dependents you are seeking coverage for. This is only required for those seeking basic coverage (SEHIP). On the first line, enter your spouse's name, birthdate and Social Security number.

 

Alabama State Employee Plan Change Form IB14 Step 8: On the next three lines, enter the same information for your children. Indicate their relationship to you by circling the appropriate label in the second column. 

 

Alabama State Employee Plan Change Form IB14 Step 9: If you are applying for supplemental coverage or Southland optional policies for vision, dental or cancer care or hospital indemnity, you must complete the last section documenting your primary insurance coverage. The first question asks you if this primary coverage has a spousal carve-out. Indicate "Yes" or "No" by circling the applicable response.

 

Alabama State Employee Plan Change Form IB14 Step 10: Provide all identifying information required about your health insurance company, as well as any dental coverage you have.

 

Alabama State Employee Plan Change Form IB14 Step 11: Sign and date the form. Mail it to the address given at the bottom of the second page.

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Refund Request IB10

Refund Request IB10

 

INSTRUCTIONS: ALABAMA REFUND REQUEST (Form IB10)

 

 

Alabama government employers can request a refund of premiums paid by their department or an employee by filing a form IB10. The document can be found on the website of the Alabama State Employees' Insurance Board.

 

Alabama Refund Request IB10 Step 1: Enter the name and number of the agency.

 

Alabama Refund Request IB10 Step 2: Indicate by checking "yes" or "no" whether the health insurance plan in question is a flex plan.

 

Alabama Refund Request IB10 Step 3: Enter the name, address and Social Security number of the employee.

 

Alabama Refund Request IB10 Step 4: Enter the dollar amount of the refund sought and the beginning and ending dates of the applicable coverage period.

 

Alabama Refund Request IB10 Step 5: You must check the box next to the statement describing why you are requesting a refund. Check the first line if seeking a refund for an employee who was terminated. Give the date of their firing.

 

Alabama Refund Request IB10 Step 6: If seeking a refund for a retired employee, check the second line and give their retirement date.

 

Alabama Refund Request IB10 Step 7; If seeking a refund for an employee who began leave without pay, check the third line and give the date on which this occurred.

 

Alabama Refund Request IB10 Step 8: If seeking a refund for an employee who requested that coverage on themselves or a dependent be dropped, check the fourth line and give the date on which this request was made. 

 

Alabama Refund Request IB10 Step 9: If seeking a refund for a dependent who died, check the fifth line and give their date of death.

 

Alabama Refund Request IB10 Step 10: If seeking a refund for an employee who died, check the sixth line and give their date of death.

 

Alabama Refund Request IB10 Step 11: If seeking a refund for a premium paid in error for an employee or dependent, check the seventh line and give the period dates during which these erroneous payments occurred.

 

Alabama Refund Request IB10 Step 12: If seeking a refund for an employee who changed their full-time status to part-time or vice-versa, check the eighth line and give the date on which this change occurred. If none of the above applies, check the ninth line and provide a written explanation. Sign the bottom of the page.

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Retiree Employment Verification IB16

Retiree Employment Verification IB16

 

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.

Download the PDF file .

Retiree Enrollment Form IB04

Retiree Enrollment Form IB04

 

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.

Download the PDF file .

Retiree Re-Employed Form

Retiree Re-Employed Form

 

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.

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