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Form IB14 State Employee Plan Change Form

Form IB14 State Employee Plan Change Form

 

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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