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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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