Revoke Election Form - State Employees' Health Insurance Coverage - Alabama
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1IB09
10/15
NOTICE: Complete ONLY if canceling dependent coverage. Not applicable for retirees.
REVOKE ELECTION FORM
State Employees’ Health Insurance Coverage
Name: ________________________________________________________________
Contract #: ________________________________
(Please Print)
Work Telephone:_________________________________________________
Agency: __________________________________________
I certify that I have incurred the following change in status:
______ Addition of dependent(s) through marriage, birth or adoption of a child, legal custody or placement for adoption;
______ Loss of dependent(s) through divorce, annulment, legal separation, death of a spouse or other dependent, or loss of
legal custody;
______ Unpaid leave of absence for you or your spouse;
______ Termination or commencement of your spouse’s or dependent’s employment;
______ Change from full-time to part -time or part-time to full-time by the employee, spouse or dependent;
______ Change from hourly to salaried payroll status or vice versa;
______ Any other change in employment status not listed that results in the gain or loss of eligibility of the employee, spouse, or
dependent;
______ Dependent’s loss of coverage due to age;
______ Change of residence or worksite of employee, spouse or dependent;
______ Compliance with Issuance of family relations judgment, decree or order (i.e., QMCSO);
______ Medicare or Medicaid entitlement of employee, spouse or dependent;
______ Taking leave under the Family and Medical Leave Act;
______ To make changes in the IRC Section 401(k) and 401(m) elective and after-tax deferrals as permitted by those sections;
______ HIPAA Special Enrollment events;
______ Significant change in medical benefits or premiums.
Date qualifying event occurred _________________________________________ (Must be within the last 30 days.)
Certification
I understand that Federal regulations prohibit me from changing the election I have made after the beginning of the Plan Year,
except under special circumstances. I understand that the change in my benefit election must be necessary or appropriate as a
result of the status change under the regulations issued by the Department of the Treasury.
I hereby certify that the information furnished in this form is true and complete to the best of my knowledge.
Employee Signature: _______________________________________________________ Date: ____________________
Employee E-mail Address:_____________________________________________________________________________
STATE EMPLOYEES’ INSURANCE BOARD
POST OFFICE BOX 304900
MONTGOMERY, ALABAMA 36130-4900
334-263-8341 / 1-866-836-9737 / FAX: 334-263-8541
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