Health/Dental Life/Disability Admin/Enroll. Forms

Health/Dental Life/Disability Admin/Enroll. Forms

Health/Dental

• Employee

  • Health & Dental Insurance Application
  • Health/Dental Change Form
  • Instructions to Complete Authorization to Release Information
  • Authorization to Release Information
  • Supplemental Authorization Forms
  • Common Law Affidavit 
  • Dental ID Card
     

• Employer

  • Certificate of Creditable Coverage Explanation
  • Certificate of Creditable Coverage
  • Employer ACH Authorization Agreement Form
  • IBBP Supply Order Form 
  • Retiree Administration
     

• Extension of Dependent Coverage/Over Age Dependents

  • Adult Children and Tax Treatment of Premiums
  • Unmarried Dependents of Iowa Bankers Benefit Plan (IBBP) covered employees, age 25
  • 2010 Dependent Flow Chart
  • 2011 Dependent Flow Chart

Life/Disability

• Employee

  • Life/Disability Coverage Application and/or Change Form
  • Voluntary High Limit AD&D Enrollment Form
  • Medical History Statement 
     

• Employer

  • IBIS Salary Report
  • Employee's Taxable Cost Worksheet of Group Term Life Insurance

COBRA Forms

• Election Form
• General Instruction Memo
• General Notice for Distribution at IBBP Health/Dental Covered Insured's Initial Enrollment
• Notices of Termination of Coverage and Unavailability of COBRA Coverage