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Form 1B02 Health Insurance Enrollment Form

Form 1B02 Health Insurance Enrollment Form

 

INSTRUCTIONS: ALABAMA HEALTH INSURANCE ENROLLMENT FORM (Form IB02)

 

 

Alabama state employees can enroll in state-administered health insurance using form IB02. This document can be obtained from the website maintained by the Alabama State Employees' Insurance Board.

 

Alabama Health Insurance Enrollment Form IB02 Step 1: Check the first box if applying for SEHIP basic medical coverage administered through Blue Cross.

 

Alabama Health Insurance Enrollment Form IB02 Step 2: Check the second box if applying supplemental coverage for secondary medical care administered through Blue Cross.

 

Alabama Health Insurance Enrollment Form IB02 Step 3: Check the third box if applying for optional policies covering vision, dental, cancer or hospital indemnity administered through Southland National.

 

Alabama Health Insurance Enrollment Form IB02 Step 4: Check the fourth box if you are declining coverage.

 

Alabama Health Insurance Enrollment Form IB02 Step 5: Enter your name in the first blank box.

 

Alabama Health Insurance Enrollment Form IB02 Step 6: Enter your sex in the second blank box.

 

Alabama Health Insurance Enrollment Form IB02 Step 7: Enter your Social Security number in the third blank box.

 

Alabama Health Insurance Enrollment Form IB02 Step 8: Enter your date of birth in the fourth blank box.

 

Alabama Health Insurance Enrollment Form IB02 Step 9: Enter your street address in the fifth blank box.

 

Alabama Health Insurance Enrollment Form IB02 Step 10: Enter your city in the sixth blank box.

 

Alabama Health Insurance Enrollment Form IB02 Step 11: Enter your state in the seventh blank box.

 

Alabama Health Insurance Enrollment Form IB02 Step 12: Enter your zip code in the eighth blank box.

 

Alabama Health Insurance Enrollment Form IB02 Step 13: Enter your home telephone number in the ninth blank box.

 

Alabama Health Insurance Enrollment Form IB02 Step 14: Enter your work phone number in the tenth blank box.

 

Alabama Health Insurance Enrollment Form IB02 Step 15: Enter your email address in the eleventh blank box.

 

Alabama Health Insurance Enrollment Form IB02 Step 16: Document your dependents as instructed in the table provided.

 

Alabama Health Insurance Enrollment Form IB02 Step 17: If applying for supplemental coverage or Southland, complete the next section concerning additional group health insurance coverage information.

 

Alabama Health Insurance Enrollment Form IB02 Step 18: Have your employer complete the bottom left hand corner.

 

Alabama Health Insurance Enrollment Form IB02 Step 19: Sign and date the form where indicated.

 

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