Transcript Order

Transcript Order for Appeal

Affidavit and Order, Suspension of Fees/Costs

Rule 16(c) Financial Report

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.

Form CL-472 Request for Reimbursement Preferred Health FSA/HRA

INSTRUCTIONS: ALABAMA REQUEST FOR REIMBURSEMENT PREFERRED HEALTH FSA/HRA (Form CL-472)

In Alabama, state employees enrolled with BlueCross BlueShield use a form CL-472 to request a reimbursement for eligible health services. This document can be obtained from the website maintained by BlueCross BlueShield of Alabama.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 1: The employee should enter their signature and the date at the top of the form where indicated.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 2: Section 1 concerns the employee. Your first name, middle initial and last name in the first three blank boxes.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 3: In the next three blank boxes, enter the month, date and year of your birth.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 4: Enter your preferred blue account number prefix in the next blank box.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 5: Enter your preferred blue account number contract number in the blank box.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 6: Enter your company name in the next blank box.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 7: Enter your work and home phone numbers in the next two blank boxes, including the area codes.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 8: Section 2 concerns the type of reimbursement being sought. Indicate whether the service was medical, vision, dental, orthodontics, RX/OTC or other by filling in the oval next to the appropriate statement.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 9: In the first two blank boxes, enter the patient's first and last names.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 10: Indicate whether the patient is self, your spouse or a dependent by filling in the appropriate oval.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 11: Indicate whether the patient is covered by insurance by filling in the appropriate oval.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 12: Provide all other information requested about the patient. You may document up to five patients on one form. Provide the amount requested for reimbursement for each service and the total at the bottom of the page.

License Cancellation/Termination Form

INSTRUCTIONS: CONNECTICUT LICENSE CANCEL/TERMINATION FORM

To request that a Connecticut license related to insurance be cancelled, use the form discussed in this article. This document can be obtained from the website maintained by the government of Connecticut.

Connecticut License Cancel/Termination Form Step 1: Enter your Connecticut license number on the first blank line or your National Producer Number (NPN) on the second blank line.

Connecticut License Cancel/Termination Form Step 2: Enter the first, middle and last name of the licensee on the third blank line.

Connecticut License Cancel/Termination Form Step 3: Enter the last four digits of the Social Security number of the licensee on the fourth blank line.

Connecticut License Cancel/Termination Form Step 4: Enter the license type on the fifth blank line.

Connecticut License Cancel/Termination Form Step 5: Enter the name of the business entity on the sixth blank line.

Connecticut License Cancel/Termination Form Step 6: Enter the federal employer identification number of the business entity on the seventh blank line.

Connecticut License Cancel/Termination Form Step 7: Indicate with a check mark whether you wish for termination of this license to take place immediately or on the license expiration date.

Connecticut License Cancel/Termination Form Step 8: Write the reason for the requested termination where indicated.

Connecticut License Cancel/Termination Form Step 9: Question 1 requires you to indicate whether you currently have any complaints or actions which are pending, active or recently deposed filed against you by any state's insurance department by circling "yes" or "no." If yes, provide a written explanation.

Connecticut License Cancel/Termination Form Step 10: Question 2 requires you to indicate whether you currently have any complaints or actions which are pending, actively or recently deposed filed against you by the Financial Industry Regulatory Authority (FINRA) by circling "yes" or "no." If yes, provide a written explanation.

Connecticut License Cancel/Termination Form Step 11: Question 3 requires you to indicate whether any insurance company has terminated your appointment with them in the last 6 months by circling "yes" or "no." If yes, write the reason.

Connecticut License Cancel/Termination Form Step 12: Provide the name, phone number and email address of a contact person.

Connecticut License Cancel/Termination Form Step 13: The licensee should sign and date the form.