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.

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.

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.

INSTRUCTIONS: ALABAMA EMPLOYER'S APPLICATION FOR SELF INSURANCE (WC Form 18)

Alabama employers who wish to self-insure payment of workers compensation in case of accident or injury on the job can do so by filing a WC Form 18. This form can be obtained from the website of the Alabama Department of Labor.

Alabama Employer's Application For Self Insurance WC 18 Step 1: Enter your business name on line 1.

Alabama Employer's Application For Self Insurance WC 18 Step 2: Enter your business address, telephone number and unemployment compensation number on line 2.

Alabama Employer's Application For Self Insurance WC 18 Step 3: On line 3, state whether you are an individual, co-partnership, limited partnership, corporation, receiver or trustee. 

Alabama Employer's Application For Self Insurance WC 18 Step 4: On the next line 1, enter a general description of your business operations. 

Alabama Employer's Application For Self Insurance WC 18 Step 5: In the chart at the bottom of the page, enter the location of all plants, the type of equipment they contain, the estimated number of employees at all points, the estimated average number of Alabama employees, and the estimated payroll for all these workers for the ensuing year.

Alabama Employer's Application For Self Insurance WC 18 Step 6: Lines 6 through 12 on the second page require you to answer questions your corporation or limited partnership.

Alabama Employer's Application For Self Insurance WC 18 Step 7: On line 13, enter the date on which you would like the self-insurance to take effect.

Alabama Employer's Application For Self Insurance WC 18 Step 8: Lines 14 and 15 ask about any current insurance policy you maintain.

Alabama Employer's Application For Self Insurance WC 18 Step 9: Answer all questions on lines 16 through 19 as directed.

Alabama Employer's Application For Self Insurance WC 18 Step 10: On line 22, enter the name of any excess insurance carrier you have, the amount of retention in dollars, and indicate whether this is specific, aggregate or both.

Alabama Employer's Application For Self Insurance WC 18 Step 11: Document your business operations as directed in the table on line 23.

Alabama Employer's Application For Self Insurance WC 18 Step 12: If you have ever filed for bankruptcy, indicate this on line 24. 

Alabama Employer's Application For Self Insurance WC 18 Step 13: Sign and date the form before a notary public.

INSTRUCTIONS: ALABAMA FEDERAL POVERTY LEVEL ASSISTANCE APPLICATION (FPL) (Form 2G)

Alabama public education employees who have a combined family income less than or equal to 200% of the Federal Poverty Level may apply for assistance. To do so, they must be enrolled in the state's Public Education Employees' Health Insurance Plan. Form 2G, used to request assistance, is located on the website of the Retirement Systems of Alabama. This document can also be used to request children's health insurance.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 1: The first section concerns subscriber information. Enter your Social Security number and name on the first line.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 2: On the second line, enter your mailing address, city, state and zip code. 

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 3: On the third line, enter your home and work phone numbers.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 4: On the fourth line, indicate whether you are married, single, divorced, legally separated or widowed with a check mark.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 5: The next section is only for those seeking children's health insurance. Indicate with a check mark whether any children are enrolled in Medicaid. If yes, give their names.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 6: A table is provided to list all household members. On line A of the first column, enter the name of the subscriber. On line B, enter the name of their spouse. On lines C through F, list all children under age 19 living in your household.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 7: In the second column, provide all listed household members' Social Security numbers.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 8: In the third column, provide all listed household members' dates of birth.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 9: In the fourth column, provide all listed household members' gender. 

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 10: In the fifth column, describe the relationship to you of all listed household members. Enter your requested effective date and answer all remaining questions as instructed.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 11: Sign and date the form. 

INSTRUCTIONS: ALABAMA ASSESSMENT REPORT FOR INSURANCE COMPANIES, SELF-INSURERS AND GROUP FUNDS (WCC Form 10)

Alabama insurance companies, group funds and self-insured businesses must file a WCC Form 10 on an annual basis. This form can be obtained from the website of the Alabama Department of Labor.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 1: Enter your company name.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 2: Enter the name of a contact person.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 3: Enter your mailing and physical address.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 4: Enter your NCCI, FEIN, SI and GSI numbers.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 5: Enter your telephone number.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 6: Enter any subsidiaries if you are a self-insured company.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 7: Enter your total compensation paid.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 8: Enter your total medical costs paid.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 9: Enter your total attorney fees paid.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 10: Enter your total administrative expenses paid.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 11: Enter your total court settlements paid.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 12: Enter the total of all these expenses.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 13: Print your name where indicated.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 14: The bottom of the form must be completed in the presence of a notary public. Print your name again and enter your corporate title.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 15: Sign the form and give your title.