INSTRUCTIONS: ALABAMA COBRA EMPLOYER NOTICE MEMO (Form IB11)

Alabama state employers notify the State Employees' Insurance Board of various changes in the status of an employee under the provisions of COBRA who is enrolled in SEHIP by filing form IB11. This document can be obtained from the website maintained by the Alabama State Employee's Insurance Board. Alternately, you may choose to file form 11 to notify the State Employees' Insurance Board of these changes in status.

Alabama COBRA Employer Notice Memo IB11 Step 1: Enter the name of the employee on the first blank line.

Alabama COBRA Employer Notice Memo IB11 Step 2: Enter the social Security number of the employee on the second blank line.

Alabama COBRA Employer Notice Memo IB11 Step 3: Enter the street number or P.O. box number of the employee on the third blank line.

Alabama COBRA Employer Notice Memo IB11 Step 4: Enter the employee's city, state and zip code on the fourth blank line.

Alabama COBRA Employer Notice Memo IB11 Step 5: Enter the name of the employer on the fifth blank line.

Alabama COBRA Employer Notice Memo IB11 Step 6: Place a check mark on line 1 if the employee has been terminated for any reason other than gross misconduct. Enter the date of their termination.

Alabama COBRA Employer Notice Memo IB11 Step 7: Place a check mark on line 2 if the employee has had a reduction in the hours of employment, including taking leave without pay. Enter the date of this reduction.

Alabama COBRA Employer Notice Memo IB11 Step 8: Place a check mark on line 3 if the employee has died. Enter the date of death.

Alabama COBRA Employer Notice Memo IB11 Step 9: Place a check mark on line 4 if the employee has become eligible for Medicare. Enter the date on which they became eligible.

Alabama COBRA Employer Notice Memo IB11 Step 10: Enter the date on the next blank line.

Alabama COBRA Employer Notice Memo IB11 Step 11: The employer should enter their signature on the next blank line.

Alabama COBRA Employer Notice Memo IB11 Step 12: File the form by mailing it to the address given at the bottom of the page. Further assistance in completing this form can also be obtained by calling the phone numbers given here.