SEIB Forms

Enrollment/Membership  

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) - Re-enroll when coverage was declined.

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

Flexible Benefits for New and Active Employees  

Discount Applications  

Tobacco/Non-Tobacco

Non-Tobacco User Discount (IB05) - Apply for the Non-Tobacco User Discount

Tobacco Cessation (IB06) - Apply for Annual Tobacco User Discount

Wellness

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

Spousal Surcharge

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 (FPL)

Federal Poverty Level Discount (IB12) - Apply for the Federal Poverty Level Discount

Claim Forms  

Miscellaneous Forms  

Agency Forms  

COBRA Form 11 (IB11) - Optional form if Personnel Form 11 is not used

Refund Request (IB10) - Request a refund of premiums paid in error