Form Ib03 - State Employee'S Membership Status Change
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2IB03
10/15
STATE EMPLOYEE’S MEMBERSHIP STATUS CHANGE
SUBSCRIBER INFO
CONTRACT NUMBER
EFFECTIVE DATE OF CHANGE
Name (First, Middle Initial, Last)
Month/Day/Year
Cancel Subscriber’s coverage (part-time employees only)
Date became part-time: ______________________________________
Check all plans this change applies to: ____ SEHIP ____ Supplemental ____ Optional ____PCO
___ BCBS Dental ___ Southland Dental ___ Southland Vision ___ Southland Cancer
DROP DEPENDENT COVERAGE
ADDITIONS – PROVIDE DOCUMENTATION
Please check appropriate box.
Please check appropriate box.
Change from Family to Single Coverage
Change from Single to Family Coverage – Add Dependent(s)
Cancel dependents listed below from Family Coverage
Add dependent(s) listed below to Family Coverage
Reason for Cancellation:
Adding Former State Employee
Death (give date):
Former Employee’s Social Security #
Divorce (copy of final divorce decree required)
Last work day:
Other (explain/give date)
Documentation is required.
Date of
First Name
Middle Initial
Last Name
Relationship to Employee
Birth
Social Security Number
Male Spouse*
Female Spouse*
Son
Daughter
Stepson
Stepdaughter
Son
Daughter
Stepson
Stepdaughter
Son
Daughter
Stepson
Stepdaughter
Grandson
Granddaughter
Nephew
Niece
*IMPORTANT: To be eligible for the non-tobacco and/or wellness discount, you must complete the Non-Tobacco User Discount Application and
meet the requirements of the Wellness Program. When adding a spouse to SEHIP coverage, a spousal surcharge of $50 per month will be
applied. To receive a discount you must submit a Spousal Surcharge Waiver Application (IB25). Forms are available at
Change Address To:
AFFIRMATION AND RELEASE
_______________________________________________
I hereby affirm that I have completely read and fully understand
Street Address
Apartment #
the terms and conditions of this form. I attest that all the
representations made by me on this form are true and correct. I
_______________________________________________
understand that any misrepresentation may result in the forfeiture
City
County
State
ZIP
of insurance coverage and that I will be personally liable for all
claims related to such misrepresentation. I further understand
that there is mandatory utilization review and I do hereby give
Work
permission to release any information necessary to evaluate,
Telephone______________________________________
administer, and process claims for benefits to any person, entity,
or representative acting on the State’s behalf.
Home
Telephone______________________________________
___________________________
_____________
Employee Signature
Date
E-Mail
State Agency:____________________________________
Address _______________________________________
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