Form Ib02 - Active Employee Health Insurance Enrollment
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2ACTIVE EMPLOYEE HEALTH INSURANCE ENROLLMENT FORM
IB02
Revised 10/15
SELECT (CHECK) ONLY ONE
SEHIP Medical *
BCBS Supplemental Coverage
Southland Optional Policies
PCO/HRA
To add dental attach Form IB21
To add dental attach Form IB21
Vision / Dental / Cancer / Hospital
Must attach Form IB26
To add vision attach Form IB20
To add vision attach Form IB20
Indemnity
To add dental attach Form IB21
To add cancer attach Form IB23
To add cancer attach Form IB23
To add vision attach Form IB20
To add cancer attach Form IB23
Vision, Dental & Cancer Only
Vision & Dental Coverage Only
Attach Forms IB20, IB21 & IB23
Attach Forms IB20 and IB21
Southland – Vision & Cancer Only
Decline All Coverage
Southland – Dental Only
Southland – Vision Only
Attach Forms IB20 and IB23
Dental & Cancer Only
Southland –Cancer Only
Blue Cross – Dental Only
Attach Forms IB21 and IB23
SUBSCRIBER INFORMATION
Name (First, Middle Initial, Last)
Sex
Social Security #
Date of Birth
Street Address:
City:
State:
ZIP Code:
Home Telephone Number:
Work Telephone Number:
E-Mail Address:
Dependent Coverage is requested for the following individuals, effective on Month ______________Day _________ Year______. Direct payment MUST be
made for any premiums that will not be payroll deducted. Make check payable to the SEIB and attach to this form.
Documentation is required for all
plans except Supplemental.
First Name
Middle Initial
Last Name
Relationship to Employee
Date of Birth
Social Security Number
Male Spouse*
Female Spouse*
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 submit a completed 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 completed Spousal Surcharge Waiver Application (IB25). Forms are available at
PRIMARY GROUP HEALTH INSURANCE COVERAGE INFORMATION
(Must be completed if choosing supplemental, optional coverage or PCO.)
Does the primary coverage have a spousal carve-out?
______ Yes
______ No
Health Insurance Company
Contract Holder
Insurance Policy #
Group #
Name of Employer
NOTE: Certain restrictions apply to high deductible plans. A summary plan description of the other coverage must be provided to document
the deductible amount. In addition please note the State Employees’ Supplemental Coverage Plan does not coordinate with the SEIB HRA
(State Employees’ Premium Cash Option [PCO]).
If choosing the Blue Cross Blue Shield (BCBS) Supplemental coverage, you cannot maintain your primary coverage through BCBS Group
13000 (State Employees’ Health Insurance Plan), Group 30000 (Local Government Health Insurance Plan, Group 14000 (Public Education
Employees’ Health Insurance Plan), or the Marketplace.
If pharmacy benefits are administered by a company other than Blue Cross Blue Shield, you will need to manually file claims for pharmacy
benefit reimbursements.
TO BE COMPLETED BY EMPLOYER
AFFIRMATION AND RELEASE
1. EMPLOYMENT STATUS:
I hereby affirm that I have completely read and fully understand the terms
and conditions of this form. I attest that all the representations made by
______Full Time _____3/4 Time _____1/2 Time
_____1/4 Time
me on this form are true and correct. I understand that any
misrepresentation may result in the forfeiture of insurance coverage and
2. EMPLOYEE’S EFFECTIVE DATE OF COVERAGE: ______________
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 permission to release any information
3. PAY FREQUENCY: ______ Semi-Monthly Arrears
necessary to evaluate, administer, and process claims for benefits to any
person, entity, or representative acting on the State’s behalf.
________ Semi-Monthly Current
________ Monthly
___________________________________
___________________
_________________________________________________________
Employee Signature
Date
Signature of Payroll Clerk
State Agency
Date
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