INSTRUCTIONS: ALABAMA RE-EMPLOYED STATE RETIREE HEALTH INSURANCE FORM (Form IB2)

Alabama retired public employees who become re-employed use the form discussed in this article to re-enroll in public employee health insurance or to decline coverage. This document can be obtained from the website maintained by the Alabama State Employees' Insurance Board.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 1: Indicate with a check mark whether you are seeking SEHIP coverage or declining coverage

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 2: Enter your first, middle and last name in the first blank box.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 3: Enter your sex in the second blank box.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 4: Enter your Social Security number in the third blank box.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 5: Enter your date of birth in the fourth blank box.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 6: Enter your Medicare number, if applicable, in the fifth blank box.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 7: Enter your street address in the sixth blank box.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 8: Enter your city in the seventh blank box.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 9: Enter your state in the eighth blank box.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 10: Enter your zip code in the ninth blank box.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 11: Enter your home telephone number, including the area code, in the tenth blank box.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 12: Enter your work telephone number, including the area code, in the eleventh blank box.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 13: If you have dependents, you must provide their full names, relationship to you, birth date and Social Security number in the table provided.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 14: Have your employer complete the bottom left section.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 15: Enter your signature and the date in the bottom right section.

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 16: Mail the form to the address given at the bottom of the page.