Health Insurance Plans
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Forms
- Automatic Draft Payment
- BC/BS Expense Claim
- BC/BS Supplemental Expense Claim
- COBRA
- Dependent Premium Conversion Plan – for Open Enrollment
- Federal Poverty Level Discount (FPL)/State Employees Children's Health Insurance Plan (SECHIP) application
- Health Insurance Enrollment (IB2)
- Medicare Part D Creditable Coverage Notice
- Membership Status Change (IB3)
- Non-Tobacco User Discount Application
- Physician Screening Form
- Plan Change Form (State Employee)
- Retired State Employee Plan Change Form
- Retiree Employment Verification
- Retiree Enrollment Form (IB4)
- Retiree Re-employed Form
- Retiree Years of Service Verification
- Refund Request
- Revoke Election Form
- Southland Hospital/Cancer Claim
- Southland Dental Claim
- Southland Vision Claim
- Southland Vision Enrollment/Cancellation Form
201 South Union Street, Suite 200 Montgomery, AL 36104
P.O. Box 304900 Montgomery, AL 36130
