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Form IB15 Retired State Employee Plan Change Form

Form IB15 Retired State Employee Plan Change Form

 

INSTRUCTIONS: ALABAMA RETIRED EMPLOYEE PLAN CHANGE FORM (Form IB15)
 
Retired Alabama employees of the state can change their health insurance coverage by filing a form IB15. This document can be obtained from the website maintained by the Alabama State Employees' Insurance Board.
 
Alabama Retired Employee Plan Change Form IB15 Step 1: At the top of the form, check the box next to the type of coverage you wish to obtain.
 
Alabama Retired Employee Plan Change Form IB15 Step 2: On the first line, provide your name, sex and the effective date of your current coverage.
 
Alabama Retired Employee Plan Change Form IB15 Step 3: On the second line, provide your Social Security number and date of birth.
 
Alabama Retired Employee Plan Change Form IB15 Step 4: On the third line, provide your street address.
 
Alabama Retired Employee Plan Change Form IB15 Step 5: On the fourth line, provide your city, state and zip code.
 
Alabama Retired Employee Plan Change Form IB15 Step 6: On the fifth line, provide your email address, as well as your work and home phone numbers.
 
Alabama Retired Employee Plan Change Form IB15 Step 7: If you are seeking to enroll in basic medical coverage administered under the Blue Cross SEHIP program, you must document your dependents. On the first line, enter the name of your husband or wife. Indicate which they are by circling the appropriate label and enter their birthdate and Social Security number. 
 
Alabama Retired Employee Plan Change Form IB15 Step 8: On the remaining lines, provide the same information for any sons, daughters, stepsons or stepdaughters.
 
Alabama Retired Employee Plan Change Form IB15 Step 9: If you are seeking to obtain Southland Optional coverage for hospital indemnity or vision, dental or cancer treatment, you must complete the last section. On the first line, enter the name of your current health insurance company, the name of the contract holder, the insurance policy and group numbers, and the name of the employer providing this coverage.
 
Alabama Retired Employee Plan Change Form IB15 Step 10: The second line asks if dental coverage is available under this retirement plan. Circle "Yes" or "No."
 
Alabama Retired Employee Plan Change Form IB15 Step 11: If dental coverage is provided, provide all information requested about it on the last line. Sign and date the bottom of the page.
 

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