Home Insurance Page 3

Insurance

Retiree Re-Employed Form

Retiree Re-Employed Form

 

INSTRUCTIONS: ALABAMA RE-EMPLOYED STATE RETIREE HEALTH INSURANCE FORM (Form IB2)

 

 

Alabama state employees who retire and are then rehired by the state government can reacquire their state health insurance by filing a form IB2. This document can be obtained from the website of the Alabama State Employees' Insurance Board. 

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 1: Indicate with a check mark if you are filing for basic SEHIP coverage from BlueCross BlueShield or whether you are declining coverage.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 2: On the first blank line, enter your full name and sex.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 3: On the second blank line, enter your Social Security number, date of birth, and (if applicable) Medicare number.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 4: On the third blank line, enter your street address.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 5: On the fourth blank line, enter your city, state and zip code.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 6: On the fifth blank line, enter your home and work telephone numbers.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 7: In the next section, you must detail any dependents for whom you are seeking coverage. On the first line, enter the full name of your husband or wife in the first column, indicate which they are by circling the correct descriptor in the second column, enter their birth date in the third column, and enter their Social Security number in the fourth column.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 8: The remainder of the table for dependents requires you to document sons, daughters, stepsons and stepdaughters. Provide their names, indicate their relationship to you, and enter their dates of birth and Social Security numbers.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 9: If you wish to receive a non-tobacco user discount on your coverage, you must submit a separate Non-Tobacco User Discount Application.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 10: The bottom left corner of the form should be completed by your employer.

 

Alabama Re-Employed State Retiree Health Insurance Form IB2 Step 11: Sign and date the bottom right corner of the form.

Download the PDF file .

Retiree Years of Service Verification IB18

Retiree Years of Service Verification IB18

 

INSTRUCTIONS: ALABAMA RETIREE YEARS OF SERVICE VERIFICATION FORM (Form IB18)

 

 

Alabama retirees may be required to a complete a form IB18 to verify service credits they have received from the Retirement Systems of Alabama that were obtained from military service, service as a public education employee or employee of the Teachers' Retirement System, or service as an employee of a postsecondary institution eligible for Public Education Employees' Health Insurance Plan coverage. This document can be obtained from the website maintained by the Alabama State Employees' Insurance Board.

 

Alabama Retiree Years Of Service Verification Form IB18 Step 1: On the first blank line on the first page, your name will be entered.

 

Alabama Retiree Years Of Service Verification Form IB18 Step 2: Your street address will be on the second blank line.

 

Alabama Retiree Years Of Service Verification Form IB18 Step 3: Your city, state and zip code will be on the third blank line.

 

Alabama Retiree Years Of Service Verification Form IB18 Step 4: Your contract number will be on the fourth blank line.

 

Alabama Retiree Years Of Service Verification Form IB18 Step 5: Your retirement date will be on the fifth blank line.

 

Alabama Retiree Years Of Service Verification Form IB18 Step 6: On the second page, check the first box if your state retirement was a disability retirement. If so, you are not required to complete any other portion of the form other than providing your signature.

 

Alabama Retiree Years Of Service Verification Form IB18 Step 7: Check the second box if the years of service credited by the Retirement Systems of Alabama do not include credit for services other than the types of teaching, military or postsecondary institution employment described in the introductory paragraph of this article.

 

Alabama Retiree Years Of Service Verification Form IB18 Step 8: If your credited years of service are other than the types discussed in the introductory paragraph, you must document them in the next section. For each such employment, enter the name of your employer, the starting and ending dates of your employment and your total months employed in this capacity.

 

Alabama Retiree Years Of Service Verification Form IB18 Step 9: Enter your total months served in non-state years of service where indicated. Sign and date the bottom of the second page and enter your contract number.

Download the PDF file .

WC Application for Self Insurance Form WC 18

WC Application for Self Insurance Form WC 18

 

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.

Download the PDF file .

Federal Poverty Level Discount (FPL) Application

Federal Poverty Level Discount (FPL) Application

 

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. 

Download the PDF file .

WC Assessment Form WCC10

WC Assessment Form WCC10

 

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.

Download the PDF file .

Revoke Election Form IB09

Revoke Election Form IB09

 

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.

Download the PDF file .

Annual Insurance Return 2013

 

INSTRUCTIONS: NEVADA ANNUAL INSURANCE PREMIUM TAX RETURN (Form IPT-R)

 

 

Nevada premium tax payments are submitted on an annual basis using the form discussed in this article. This document can be obtained from the website of the Nevada Department of Taxation.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 1: In the top right-hand corner, enter your tax identification number, federal ID, premium tax, retaliatory tax and total remittance.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 2: On line 1, enter your total premiums and consideration.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 3: On line 2, multiply line 1 by 3.5% and enter the resulting product. If a qualified risk retention group, multiply line 1 by 2% and enter the resulting product.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 4: On line 3a, if you qualify, calculate your home office credit as instructed.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 5: If qualified, enter the amount of ad valorem taxes paid on line 3b.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 6: Enter the maximum credit allowed on line 3c.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 7: Enter your allowable home office credits on line 3d.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 8: Subtract line 3d from line 2. Enter the resulting difference on line 4.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 9: Enter your life/health guaranty association offset on line 5.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 10: On line 6, enter your property/casualty guaranty association offset.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 11: On line 6A, enter the total overpayments applied from previous years.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 12: On line 6B, enter the total overpayments refunded by Nevada for the year specified.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 13: On line 7, enter your net premium tax due.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 14: If filing late, calculate your penalty and daily interest due on lines 8 and 9 as instructed.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 15: Add lines 7 through 9. Enter the resulting sum on line 10.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 16: Sign and print your name. Enter the date, your email address and telephone number.

 

Download the PDF file .

Retired State Employee Plan Change Form IB15

Retired State Employee Plan Change Form IB15

 

INSTRUCTIONS: ALABAMA RETIRED EMPLOYEE PLAN CHANGE FORM (Form IB15)

 

 

Retired Alabama employees of the state can change their health insurance coverage by filing a form IB15. This document can be obtained from the website maintained by the Alabama State Employees' Insurance Board.

 

Alabama Retired Employee Plan Change Form IB15 Step 1: At the top of the form, check the box next to the type of coverage you wish to obtain.

 

Alabama Retired Employee Plan Change Form IB15 Step 2: On the first line, provide your name, sex and the effective date of your current coverage.

 

Alabama Retired Employee Plan Change Form IB15 Step 3: On the second line, provide your Social Security number and date of birth.

 

Alabama Retired Employee Plan Change Form IB15 Step 4: On the third line, provide your street address.

 

Alabama Retired Employee Plan Change Form IB15 Step 5: On the fourth line, provide your city, state and zip code.

 

Alabama Retired Employee Plan Change Form IB15 Step 6: On the fifth line, provide your email address, as well as your work and home phone numbers.

 

Alabama Retired Employee Plan Change Form IB15 Step 7: If you are seeking to enroll in basic medical coverage administered under the Blue Cross SEHIP program, you must document your dependents. On the first line, enter the name of your husband or wife. Indicate which they are by circling the appropriate label and enter their birthdate and Social Security number. 

 

Alabama Retired Employee Plan Change Form IB15 Step 8: On the remaining lines, provide the same information for any sons, daughters, stepsons or stepdaughters.

 

Alabama Retired Employee Plan Change Form IB15 Step 9: If you are seeking to obtain Southland Optional coverage for hospital indemnity or vision, dental or cancer treatment, you must complete the last section. On the first line, enter the name of your current health insurance company, the name of the contract holder, the insurance policy and group numbers, and the name of the employer providing this coverage.

 

Alabama Retired Employee Plan Change Form IB15 Step 10: The second line asks if dental coverage is available under this retirement plan. Circle "Yes" or "No."

 

Alabama Retired Employee Plan Change Form IB15 Step 11: If dental coverage is provided, provide all information requested about it on the last line. Sign and date the bottom of the page.

Download the PDF file .

Annual IIPT(WC) Reconciliation 2013

 

INSTRUCTIONS: NEVADA ANNUAL INSURANCE PREMIUM TAX RETURN (Form IPT-R)

 

 

Nevada businesses and residents pay their annual insurance premium tax using the form discussed in this article. This form can be obtained from the website of the Nevada Department of Taxation.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 1: In the top right-hand corner, enter your tax identification number, federal ID, premium tax, retaliatory tax and total remittance.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 2: On line 1, enter the total premium tax and considerations.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 3: On line 2, follow the directions to determine the gross premium tax owed.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 4: If qualified, calculate the amount of home office credit applicable on line 3a as instructed.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 5: If qualified for this credit, enter the amount of ad valorem taxes paid on line 3b.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 6: If applicable, enter the maximum credit allowed on line 3.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 7: On line 3d, enter your allowable home office credits.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 8: Subtract line 3d from line 2. enter the resulting difference on line 4.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 9: Enter the life/health guaranty association offset on line 5.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 10: Enter the property/casualty guaranty association credit on line 6.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 11: Enter total overpayments applied from previous years on line 6A.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 12: Enter total overpayments refunded by Nevada for the year listed on line 6B.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 13: Enter your net premium tax due on line 7.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 14: If filing late, calculate your penalty due as instructed on line 8.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 15: If filing late, calculate the interest owed as instructed on line 9.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 16: Enter the sum of lines 7 through 9 on line 10.

 

Nevada Annual Insurance Premium Tax Return IPT-R Step 17: Sign and print your name. Provide the date, your phone number and email address.

 

Download the PDF file .

Southland Vision Enrollment/Cancellation Form IB20

Southland Vision Enrollment/Cancellation Form IB20

 

INSTRUCTIONS: SOUTHLAND NATIONAL SUPPLEMENTAL VISION INSURANCE ENROLLMENT/CANCELLATION FORM (Form IB20)

 

 

Alabama state employees who wish to enroll in state-administered supplemental vision insurance do so by filing a form IB20. This document can be obtained from the website of the Alabama State Employees' Insurance board.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 1: On the first line, enter your name, sex, and the date you wish for the coverage to take effect.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 2: On the second line, give your Social Security number and date of birth.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 3: On the third line, give your mailing address.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 4: On the fourth line, give your city, state and zip code.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 5: On the fifth line, give your home and work telephone numbers. 

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 6: On the sixth line, give your email address.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 7: In the box on the right, indicate with a check mark if you are seeking single or family vision coverage or whether you are filing this form to cancel coverage currently in effect.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 8: If you are seeking family coverage, you must detail your dependents. In the first column on the first line, enter the first name, middle initial and last name of your husband or wife. In the second column, circle "Husband" or "Wife" as applicable. In the third column, enter their date of birth. In the fourth column, enter their Social Security number.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 9: The next three lines require you to enter the same information for any sons, daughters, stepsons or stepdaughters.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 10: The last two lines provided require you to enter the same information for any grandsons, granddaughters, nephews and nieces.

 

Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 11: Sign and date the bottom of the first page. Mail the completed document to the address at the bottom of the second page.

Download the PDF file .