Health Insurance and Optional Status Change
INSTRUCTIONS: ALABAMA EMPLOYER'S APPLICATION FOR SELF INSURANCE (WC Form 18)
Alabama employers who wish to self-insure payment of workers compensation in case of accident or injury on the job can do so by filing a WC Form 18. This form can be obtained from the website of the Alabama Department of Labor.
Alabama Employer's Application For Self Insurance WC 18 Step 1: Enter your business name on line 1.
Alabama Employer's Application For Self Insurance WC 18 Step 2: Enter your business address, telephone number and unemployment compensation number on line 2.
Alabama Employer's Application For Self Insurance WC 18 Step 3: On line 3, state whether you are an individual, co-partnership, limited partnership, corporation, receiver or trustee.
Alabama Employer's Application For Self Insurance WC 18 Step 4: On the next line 1, enter a general description of your business operations.
Alabama Employer's Application For Self Insurance WC 18 Step 5: In the chart at the bottom of the page, enter the location of all plants, the type of equipment they contain, the estimated number of employees at all points, the estimated average number of Alabama employees, and the estimated payroll for all these workers for the ensuing year.
Alabama Employer's Application For Self Insurance WC 18 Step 6: Lines 6 through 12 on the second page require you to answer questions your corporation or limited partnership.
Alabama Employer's Application For Self Insurance WC 18 Step 7: On line 13, enter the date on which you would like the self-insurance to take effect.
Alabama Employer's Application For Self Insurance WC 18 Step 8: Lines 14 and 15 ask about any current insurance policy you maintain.
Alabama Employer's Application For Self Insurance WC 18 Step 9: Answer all questions on lines 16 through 19 as directed.
Alabama Employer's Application For Self Insurance WC 18 Step 10: On line 22, enter the name of any excess insurance carrier you have, the amount of retention in dollars, and indicate whether this is specific, aggregate or both.
Alabama Employer's Application For Self Insurance WC 18 Step 11: Document your business operations as directed in the table on line 23.
Alabama Employer's Application For Self Insurance WC 18 Step 12: If you have ever filed for bankruptcy, indicate this on line 24.
Alabama Employer's Application For Self Insurance WC 18 Step 13: Sign and date the form before a notary public.
INSTRUCTIONS: ALABAMA FEDERAL POVERTY LEVEL ASSISTANCE APPLICATION (FPL) (Form 2G)
Alabama public education employees who have a combined family income less than or equal to 200% of the Federal Poverty Level may apply for assistance. To do so, they must be enrolled in the state's Public Education Employees' Health Insurance Plan. Form 2G, used to request assistance, is located on the website of the Retirement Systems of Alabama. This document can also be used to request children's health insurance.
Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 1: The first section concerns subscriber information. Enter your Social Security number and name on the first line.
Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 2: On the second line, enter your mailing address, city, state and zip code.
Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 3: On the third line, enter your home and work phone numbers.
Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 4: On the fourth line, indicate whether you are married, single, divorced, legally separated or widowed with a check mark.
Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 5: The next section is only for those seeking children's health insurance. Indicate with a check mark whether any children are enrolled in Medicaid. If yes, give their names.
Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 6: A table is provided to list all household members. On line A of the first column, enter the name of the subscriber. On line B, enter the name of their spouse. On lines C through F, list all children under age 19 living in your household.
Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 7: In the second column, provide all listed household members' Social Security numbers.
Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 8: In the third column, provide all listed household members' dates of birth.
Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 9: In the fourth column, provide all listed household members' gender.
Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 10: In the fifth column, describe the relationship to you of all listed household members. Enter your requested effective date and answer all remaining questions as instructed.
Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 11: Sign and date the form.
INSTRUCTIONS: ALABAMA ASSESSMENT REPORT FOR INSURANCE COMPANIES, SELF-INSURERS AND GROUP FUNDS (WCC Form 10)
Alabama insurance companies, group funds and self-insured businesses must file a WCC Form 10 on an annual basis. This form can be obtained from the website of the Alabama Department of Labor.
Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 1: Enter your company name.
Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 2: Enter the name of a contact person.
Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 3: Enter your mailing and physical address.
Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 4: Enter your NCCI, FEIN, SI and GSI numbers.
Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 5: Enter your telephone number.
Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 6: Enter any subsidiaries if you are a self-insured company.
Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 7: Enter your total compensation paid.
Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 8: Enter your total medical costs paid.
Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 9: Enter your total attorney fees paid.
Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 10: Enter your total administrative expenses paid.
Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 11: Enter your total court settlements paid.
Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 12: Enter the total of all these expenses.
Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 13: Print your name where indicated.
Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 14: The bottom of the form must be completed in the presence of a notary public. Print your name again and enter your corporate title.
Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 15: Sign the form and give your title.
INSTRUCTIONS: ALABAMA REVOKE ELECTION FORM STATE EMPLOYEES' HEALTH INSURANCE COVERAGE (Form IB09)
To cancel dependent coverage included in Alabama state employees' health insurance coverage, a form IB09 should be used. This document can be obtained from the website of the Alabama State Employees' Insurance Board.
Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 1: Print your name on the first blank line.
Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 2: Enter your contract number on the second blank line.
Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 3: Enter your work telephone number on the third blank line.
Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 4: Enter your agency name on the fourth blank line.
Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 5: Check the line next to the first statement if you have added dependents through marriage, birth or adoption of a child. Check the line next to the second statement if you have lost dependents.
Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 6: The next five statements concern various changes in the employment status of you or your spouse. Check the line next to any applicable statements.
Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 7: Check the next line if the dependant has lost coverage due to their age.
Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 8: Check the next line if you are documenting a change of residence or worksite.
Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 9: Check the next line if you are complying with a family relations judgment, decree or order.
Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 10: Check the next line if revoking coverage due to a Medicare or Medicaid entitlement.
Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 11: Check the next line if taking leave under the Family and Medical Leave act.
Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 12: Check any of the next three lines if applicable.
Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 13: On the next blank line, enter the date on which the qualifying event occurred. Sign and date the bottom of the page.