Form 1095-B Request

For Mississippi State and School Employees’ Health Insurance Plan COBRA and Retiree Participants

Please enter the information below to request a Form 1095-B in the mail. Only the primary Participant (i.e., not a Dependent) on the policy/plan may request and receive a Form 1095-B.

If you have coverage as an active employee through the Mississippi State and School Employees’ Health Insurance Plan, Blue Cross & Blue Shield of Mississippi does not issue your Form 1095-B and you should not submit the request below.

Participant ID - Do not include the prefix. View Example

Participant's Last Name

Participant's Date of Birth - Format: MM/DD/YYYY

Participant's Zip Code

Request Form 1095-B