New State Employees

• Health Insurance Enrollment (IB2) - New employees only
• Non-Tobacco User Discount Application
• Physician Screening Form

Active Employees

• Blue Cross Blue Shield Basic Medical
• BC/BS Expense Claim
• BC/BS Supplemental Expense Claim
• COBRA Form 11
• Dependent Premium Conversion Plan – for Open Enrollment
• Federal Poverty Level Discount (FPL)/State Employees Children's Health Insurance Plan (SECHIP) application
• Membership Status Change (IB3)
• Revoke Election Form
• Non-Tobacco User Discount Application
• Physician Screening Form
• Plan Change Form (State Employee)
• Refund Request

Retirees

• Blue Cross Blue Shield Basic Medical
• BC/BS Expense Claim
• BC/BS Supplemental Expense Claim
• Medicare Part D Creditable Coverage Notice
• Membership Status Change (IB3)
• Non-Tobacco User Discount Application
• Retired State Employee Plan Change Form
• Retiree Employment Verification
• Retiree Enrollment Form (IB4)
• Retiree Re-employed Form
• Retiree Years of Service Verification

Southland National

• Southland Vision Enrollment/Cancellation Form
• Southland Claim Forms
• Southland Hospital/Cancer Claim
• Southland Dental Claim
• Southland Vision Claim

Miscellaneous Forms

• Automatic Draft Payment