New Employee Enrollment (IB02) - New employees who wish to enroll or decline coverage and employees re-enrolling who are returning from LWOP
Retired Employee Enrollment (IB04) - Retirees who wish to enroll or decline coverage and retirees re-enrolling who had a break in coverage.
Active and Retired Employee Status Change (IB03) - Add/drop dependent coverage, add a dependent to existing coverage, cancel a dependent from existing coverage. Update address, telephone numbers and email address. Cancel part-time employee coverage.
Active and Retired Employee Plan Change (IB14) - Active state employees and retirees change plans, change plans during open enrollment, and decline coverage. Active employees to re-enroll when coverage was declined.
Active Employee Dependent Revoke Election (IB09) - Cancel depedent coverage outside of Open Enrollment
Retired Employee Employment Verification (IB16) - Declare a change in employment status
Re-Employed Retired Employee Enrollment (IB17) - Retiree is re-employed with a state agency. More Information
Retired Employee Years of Creditable Coverage Verification (IB18) - Verify years of creditable coverage
Ineligible Status (IB35)
2023 Enrollment Form HCRA / DCRA
Request for Reimbursement Dependent Care Reimbursement Account
Request for Reimbursement Health Care Reimbursement Account
Qualifying Change in Status Form
Non-Tobacco User Discount (IB05) - Apply for the Non-Tobacco User Discount
Tobacco Cessation (IB06) - Apply for Annual Tobacco User Discount
Wellness Provider Screening (Take this one to your Doctor) (IB13) - Apply for the Wellness Premium Discount
Active and Retired Employee Wellness Post Screening Qualification (IB07) - Provide proof that identified health risks have been addressed
New and Active State Employees Spousal Surcharge Waiver Application (IB25) - Apply for the Spousal Surcharge Waiver
Unemployed or Retired Spouse Verification (IB27) - Submit with Spousal Surcharge Waiver Form if spouse has retired or become unemployed since last filed tax return
Retired Employee Spousal Surcharge Waiver Application (IB28) - Apply for Spousal Surcharge Waiver
Federal Poverty Level Discount (IB12) - Apply for the Federal Poverty Level Discount
Medical Expense Claim
Dental Expense Claim
Supplemental Expense Claim
Supplemental Pharmacy Expense Claim
Supplemental Claim Electronic Funds Transfer Form
PCO Manual Claim
How to Set up Recurring Claims on CYC
Hospital / Cancer Claim
Dental Claim
Vision Claim
Automatic Draft Payment (IB19) - Apply for automatic bank draft payments
Authorization for Disclosure of Protected Health Information
SEIB Admin Guide
COBRA Form 11 (IB11) - Optional form if Personnel Form 11 is not used
Refund Request (IB10) - Request a refund of premiums paid in error
