INSTRUCTIONS: ALABAMA PEEHIP HEALTH INSURANCE AND OPTIONAL ENROLLMENT APPLICATION
Alabama public employees can use the form discussed in this article to apply for PEEHIP health insurance and optional enrollment. This document can be obtained from the website of the Retirement Systems of Alabama.
Alabama PEEHIP Health Insurance And Optional Enrollment Application Step 1: Indicate with a check mark whether you are an active or retired member.
Alabama PEEHIP Health Insurance And Optional Enrollment Application Step 2: The first section concerns the subscriber. On the first line, enter your Social Security number, first name, middle name or initial and last name.
Alabama PEEHIP Health Insurance And Optional Enrollment Application Step 3: On the second line, enter your mailing street address, city, state and zip code.
Alabama PEEHIP Health Insurance And Optional Enrollment Application Step 4: On the third line, enter your date of birth and home and work phone numbers. Indicate your gender with a check mark.
Alabama PEEHIP Health Insurance And Optional Enrollment Application Step 5: On the fourth line, indicate your marital status with a check mark.
Alabama PEEHIP Health Insurance And Optional Enrollment Application Step 6: On the fifth line, enter your employer or school system, email address and date of employment.
Alabama PEEHIP Health Insurance And Optional Enrollment Application Step 7: Indicate with a check mark whether you or your spouse have used tobacco products in the last 12 months.
Alabama PEEHIP Health Insurance And Optional Enrollment Application Step 8: The next section concerns the PEEHIP coverage being sought. Indicate the type of basic hospital/medical plan you are seeking, along with any optional coverages, with check marks. Enter your requested effective dates for both types of coverage.
Alabama PEEHIP Health Insurance And Optional Enrollment Application Step 9: The next section concerns dependents and should only be completed if seeking family coverage.
Alabama PEEHIP Health Insurance And Optional Enrollment Application Step 10: The next section must be completed if the member elects the PEEHIP Supplemental plan or if the member or their dependents have other group health, dental or vision coverage currently in effect.
Alabama PEEHIP Health Insurance And Optional Enrollment Application Step 11: The next section must be completed if you or your dependents are eligible for Medicare. The following section is only for members who retired after September 30, 2005. Sign and date the bottom of the second page.