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Plan Change Form State Employee IB14

Plan Change Form State Employee IB14

 

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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Refund Request IB10

Refund Request IB10

 

INSTRUCTIONS: ALABAMA REFUND REQUEST (Form IB10)

 

 

Alabama government employers can request a refund of premiums paid by their department or an employee by filing a form IB10. The document can be found on the website of the Alabama State Employees' Insurance Board.

 

Alabama Refund Request IB10 Step 1: Enter the name and number of the agency.

 

Alabama Refund Request IB10 Step 2: Indicate by checking "yes" or "no" whether the health insurance plan in question is a flex plan.

 

Alabama Refund Request IB10 Step 3: Enter the name, address and Social Security number of the employee.

 

Alabama Refund Request IB10 Step 4: Enter the dollar amount of the refund sought and the beginning and ending dates of the applicable coverage period.

 

Alabama Refund Request IB10 Step 5: You must check the box next to the statement describing why you are requesting a refund. Check the first line if seeking a refund for an employee who was terminated. Give the date of their firing.

 

Alabama Refund Request IB10 Step 6: If seeking a refund for a retired employee, check the second line and give their retirement date.

 

Alabama Refund Request IB10 Step 7; If seeking a refund for an employee who began leave without pay, check the third line and give the date on which this occurred.

 

Alabama Refund Request IB10 Step 8: If seeking a refund for an employee who requested that coverage on themselves or a dependent be dropped, check the fourth line and give the date on which this request was made. 

 

Alabama Refund Request IB10 Step 9: If seeking a refund for a dependent who died, check the fifth line and give their date of death.

 

Alabama Refund Request IB10 Step 10: If seeking a refund for an employee who died, check the sixth line and give their date of death.

 

Alabama Refund Request IB10 Step 11: If seeking a refund for a premium paid in error for an employee or dependent, check the seventh line and give the period dates during which these erroneous payments occurred.

 

Alabama Refund Request IB10 Step 12: If seeking a refund for an employee who changed their full-time status to part-time or vice-versa, check the eighth line and give the date on which this change occurred. If none of the above applies, check the ninth line and provide a written explanation. Sign the bottom of the page.

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Retiree Employment Verification IB16

Retiree Employment Verification IB16

 

INSTRUCTIONS: ALABAMA RETIREE EMPLOYMENT VERIFICATION FORM (Form IB-16)

 

 

Alabama state employees who retire after September 30, 2005 are required to make use of any new employer's health benefit plan for primary coverage if the plan covers at least 50% of expenses. You can continue using state employees' insurance if necessary for supplemental and optional coverage. This form can be obtained from the website of the Alabama State Employees' Insurance Plan.

 

Alabama Retiree Employment Verification Form IB-16 Step 1: The first question on the reverse side of the letter you receive containing form IB-16 asks if you are currently employed. Check "Yes" or "No." If the latter, you do not need to complete the rest of the form. Sign, date and file the form.

 

Alabama Retiree Employment Verification Form IB-16 Step 2: On the first blank line of question 1, give your current employer's name.

 

Alabama Retiree Employment Verification Form IB-16 Step 3: On the second and third lines, give your current employer's address.

 

Alabama Retiree Employment Verification Form IB-16 Step 4: On the fourth blank line, provide your current employer's phone number including the area code.

 

Alabama Retiree Employment Verification Form IB-16 Step 5: On the fifth blank line, give the date on which you were hired.

 

Alabama Retiree Employment Verification Form IB-16 Step 6: Question 2 asks if your employer offers group health insurance. Check "Yes" or "No" as applicable. If the latter, you do not need to answer the remaining questions. Sign, date and file the form.

 

Alabama Retiree Employment Verification Form IB-16 Step 7: Question 3 asks if your employer contributes half or more of the cost of single health insurance coverage for employees. Check "Yes" or "No" as applicable. If the latter, you do not need to answer the last question. Sign, date and file the form.

 

Alabama Retiree Employment Verification Form IB-16 Step 8: Question 4 asks if you are eligible for your employer's group health insurance coverage. Check "Yes" or "No" as applicable. If "No," provide a written explanation.

 

Alabama Retiree Employment Verification Form IB-16 Step 9: Sign and date the form.

 

Alabama Retiree Employment Verification Form IB-16 Step 10: If your new employer ceases to pay at least 50% of the cost of single coverage, you may apply to re-enroll in the State Employees' Health Insurance Plan.

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Retiree Enrollment Form IB04

Retiree Enrollment Form IB04

 

INSTRUCTIONS: ALABAMA RETIREE HEALTH INSURANCE ENROLLMENT FORM (Form IB04)

 

 

Alabama state employees who retire can enroll for health insurance through the state using a form IB04. This document can be obtained from the website maintained by the Alabama State Employees' Health Insurance Program.

 

Alabama Retiree Health Insurance Enrollment Form IB04 Step 1: Indicate with a check mark whether you are seeking basic SEHIP coverage, dental coverage only from Blue Cross, supplemental Blue Cross coverage, or optional Southland policies concerning vision, dental, cancer and hospital indemnity.

 

Alabama Retiree Health Insurance Enrollment Form IB04 Step 2: On the first line of the first table, enter your full name and sex.

 

Alabama Retiree Health Insurance Enrollment Form IB04 Step 3: On the second line, enter your Social Security number and date of birth.

 

Alabama Retiree Health Insurance Enrollment Form IB04 Step 4: On the third line, enter your street address.

 

Alabama Retiree Health Insurance Enrollment Form IB04 Step 5: On the fourth line, enter your city, county, state and zip code.

 

Alabama Retiree Health Insurance Enrollment Form IB04 Step 6: On the fifth line, enter your home and work telephone numbers.

 

Alabama Retiree Health Insurance Enrollment Form IB04 Step 7: If you are seeking dependent coverage, enter the date on which you request it to take effect.

 

'Alabama Retiree Health Insurance Enrollment Form IB04 Step 8: The next table requires you to list all dependents. The first line is for your husband or wife if applicable. Give their name in the first column, indicate whether they are your husband or wife with a check mark in the second column, give their date of birth in the third column, and enter their Social Security number in the fourth column.

 

Alabama Retiree Health Insurance Enrollment Form IB04 Step 9: The remaining lines of this table require the same information for any dependent children.

 

Alabama Retiree Health Insurance Enrollment Form IB04 Step 10: If you have additional group health insurance coverage, document it below. Indicate with a check mark whether this coverage is Medicare A, Medicare B or another insurance. If the latter, specify the coverage.

 

Alabama Retiree Health Insurance Enrollment Form IB04 Step 11: List the name of any health insurance and/or dental insurance company, the contract holder, the insurance policy and group numbers, and the providing employer's name. Sign and date the bottom of the page.

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Retiree Re-Employed Form

Retiree Re-Employed Form

 

INSTRUCTIONS: ALABAMA RE-EMPLOYED STATE RETIREE HEALTH INSURANCE FORM (Form IB2)

 

 

Alabama state employees who retire and are then rehired by the state government can reacquire their state health insurance by filing a form IB2. This document can be obtained from the website of the Alabama State Employees' Insurance Board. 

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 1: Indicate with a check mark if you are filing for basic SEHIP coverage from BlueCross BlueShield or whether you are declining coverage.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 2: On the first blank line, enter your full name and sex.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 3: On the second blank line, enter your Social Security number, date of birth, and (if applicable) Medicare number.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 4: On the third blank line, enter your street address.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 5: On the fourth blank line, enter your city, state and zip code.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 6: On the fifth blank line, enter your home and work telephone numbers.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 7: In the next section, you must detail any dependents for whom you are seeking coverage. On the first line, enter the full name of your husband or wife in the first column, indicate which they are by circling the correct descriptor in the second column, enter their birth date in the third column, and enter their Social Security number in the fourth column.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 8: The remainder of the table for dependents requires you to document sons, daughters, stepsons and stepdaughters. Provide their names, indicate their relationship to you, and enter their dates of birth and Social Security numbers.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 9: If you wish to receive a non-tobacco user discount on your coverage, you must submit a separate Non-Tobacco User Discount Application.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 10: The bottom left corner of the form should be completed by your employer.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 11: Sign and date the bottom right corner of the form.

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