Home Retirement Form 12, Insurance Authorization

Form 12, Insurance Authorization

Form 12, Insurance Authorization

 

INSTRUCTIONS: ALABAMA INSURANCE AUTHORIZATION FORM (Form 12)
 
Alabama judges enrolled in the Judicial Retirement Fund use Form 12 to authorize monthly premium deductions for health insurance from their retirement fund. This document is also used to authorize or revoke coverage for dependents, as well as to discontinue coverage. Form 12 can be found on the website maintained by the Retirement Systems of Alabama.
 
Alabama Insurance Authorization Form 12 Step 1: On the first line, enter your name.
 
Alabama Insurance Authorization Form 12 Step 2: On the second line, enter your date of birth.
 
Alabama Insurance Authorization Form 12 Step 3: On the third line, enter your Social Security number.
 
Alabama Insurance Authorization Form 12 Step 4: On the fourth line, enter your home phone number.
 
Alabama Insurance Authorization Form 12 Step 5: On the fifth line, enter your complete home address.
 
Alabama Insurance Authorization Form 12 Step 6: If you are enrolled in the state employees' health insurance plan, check the box next to the first statement.
 
Alabama Insurance Authorization Form 12 Step 7: If you are enrolled in another health insurance plan, check the box next to the second statement and write the name of your insurance plan.
 
Alabama Insurance Authorization Form 12 Step 8: Indicate with a check mark whether you do or do not wish to continue health insurance coverage for dependents. 
 
Alabama Insurance Authorization Form 12 Step 9: In the table provided, enter the last name, first name, middle name, birthdate, sex and relationship to you of every dependent.
 
Alabama Insurance Authorization Form 12 Step 10: If you wish to discontinue your health insurance coverage, check the box next to the statement stating this.
 
Alabama Insurance Authorization Form 12 Step 11: The last table provided requires you to list authorized miscellaneous insurance deductions if applicable. In the first column, give the name of the company.
 
Alabama Insurance Authorization Form 12 Step 12: In the second column, give the policy number.
 
Alabama Insurance Authorization Form 12 Step 13: In the third column, enter the amount of your monthly premium.
 
Alabama Insurance Authorization Form 12 Step 14: Sign and date the form.
 
Alabama Insurance Authorization Form 12 Step 15: Submit the document to your payroll clerk, who will sign and date the form. The document should then be filed with the Judicial Retirement Fund.
 

Download the PDF file .

Comments

comments