Fillable Refund Request Form - State Employees' Insurance Board printable pdf download

Refund Request Form - State Employees' Insurance Board

Download a blank fillable Refund Request Form - State Employees' Insurance Board in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Refund Request Form - State Employees' Insurance Board with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

IB10

SEIB OFFICE USE ONLY

Revised 10/15

OK TO REFUND

_____________ ________

Mo/Day/Year

STATE EMPLOYEES’ INSURANCE BOARD

POST OFFICE BOX 304900

MONTGOMERY, ALABAMA 36130-4900

334.263.8341 / FAX: 334.263.8541

REFUND REQUEST

A refund of State Employees’ Health Insurance premiums is requested for the department and/or employee

referenced below:

Agency Identification Data

Employee Identification Data

Agency name___________________________

Employee name________________________________

Agency No. ____________________________

Address:______________________________________

City: __________________State: ____ ZIP: _________

Flex Plan: Yes________ No_________

Social Security #________________________________

Refund amount $_______________

Coverage Period: __________________ through ______________

Reason for requesting refund of premiums (check the appropriate line):

____ Employee terminated: Date_______________

____ Employee retired: Date_______________

____ Employee began leave without pay: Date_______________

____ Employee notified SEIB on ______________ to drop coverage on _____Employee ____ Dependent

Effective date______________

(attach change form)

____ Dependent died: Date_____________

____ Employee died: Date_______________

____ Coverage was paid/deducted in error on ______Employee _____Dependent

for the period of _______________ through _______________

____ Employee status changes to ____full time ____part-time: Date _______________

____ Other reason. Please explain_______________________________________________________

___________________________________________________________________________________

_________________________________________

Signature of Official requesting refund

Refund Request Form - State Employees' Insurance Board

Related Articles

Related forms

Related Categories