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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.