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

If required to file Nevada quarterly insurance premium tax returns during the year, an annual reconciliation form must be filed. This document can be found on the website of the Nevada Department of Taxation.

Nevada Annual Insurance Premium Tax Reconciliation 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 Reconciliation Return IPT-R Step 2: On lines 1 through 4, enter your reported and actual quarterly taxable premiums for the quarters listed.

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 3: Enter the total of the figures on lines 1 through 4 on line 5.

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 4: On line 6, enter your total premiums and consideration.

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 5: On line 7, calculate your gross premium tax as instructed.

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 6: If you qualify, calculate your home office credit as instructed on line 8a.

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 7: If you qualify for a home office credit, enter the amount of ad valorem taxes paid on line 8b.

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 8: Enter the maximum credit allowed on line 8c.

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 9: Enter the allowable home office credit on line 8d.

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 10: Subtract line 8d from line 7. Enter the resulting difference on line 9.

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 11: Enter the life/health guaranty association offset on line 10 and the property/casualty guaranty association credit on line 11.

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 12: Enter total payments made with your quarterly payments on line 12. Do not include penalties or interest.

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 13: On line 13, enter any overpayment and specify the year.

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 14: On line 14, enter the net premium tax due. 

Nevada Annual Insurance Premium Tax Reconciliation Return IPT-R Step 15: Complete the rest of the form as instructed.

INSTRUCTIONS: ALABAMA HEALTH INSURANCE ENROLLMENT FORM (Form IB02)

Alabama state employees file for health insurance for themselves and qualifying dependents using a form IB02. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

Alabama Health Insurance Enrollment Form IB02 Step 1: Indicate with a check mark if you are filing for basic medical coverage, secondary supplemental coverage, optional policies for vision, dental and hospital indemnity, or if you are declining coverage.

Alabama Health Insurance Enrollment Form IB02 Step 2: Enter your full name and sex.

Alabama Health Insurance Enrollment Form IB02 Step 3: Enter your Social Security number and date of birth.

Alabama Health Insurance Enrollment Form IB02 Step 4: Enter your street address, city, state and zip code.

Alabama Health Insurance Enrollment Form IB02 Step 5: Enter your home and work telephone numbers, as well as your email address.

Alabama Health Insurance Enrollment Form IB02 Step 6: Enter the date on which you are requesting that coverage take effect for dependents.

Alabama Health Insurance Enrollment Form IB02 Step 7: The next section requires you to list all dependents you are seeking coverage for. Enter their name, indicate their relationship to you with a check mark, and provide their date of birth and Social Security number. Note that you cannot obtain coverage for a divorced or common-law spouse.

Alabama Health Insurance Enrollment Form IB02 Step 8: If you have additional group health insurance, indicate whether it has a spousal-carve out.

Alabama Health Insurance Enrollment Form IB02 Step 9: Enter the name of the company providing this insurance.

Alabama Health Insurance Enrollment Form IB02 Step 10: Enter the name of the contract holder and the policy number.

Alabama Health Insurance Enrollment Form IB02 Step 11: Enter the group number and the name of the employer providing this insurance.

Alabama Health Insurance Enrollment Form IB02 Step 12: Indicate with a check mark whether this plan includes dental coverage. If so, you must give the name of the dental insurance company, the policy and group number, and the name of the providing employer.

Alabama Health Insurance Enrollment Form IB02 Step 13: The section at the bottom left should be completed by your current employer.

Alabama Health Insurance Enrollment Form IB02 Step 14: Sign and date the form at the bottom right.

INSTRUCTIONS: ALABAMA PROVIDER SCREENING FORM (Form IB13)

Alabama state employees who choose not to participate in Worksite Wellness screenings may instead submit health screening results through a healthcare provider. This is done using a form IB13. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

Alabama Provider Screening Form IB13 Step 1: Section 1 should be completed by the employee. In the first blank box, enter your name.

Alabama Provider Screening Form IB13 Step 2: In the second blank box, enter the screening date.

Alabama Provider Screening Form IB13 Step 3: In the third blank box, indicate whether you are male or female with a check mark.

Alabama Provider Screening Form IB13 Step 4: In the fourth blank box, enter your age.

Alabama Provider Screening Form IB13 Step 5: In the fifth blank box, enter your contract number.

Alabama Provider Screening Form IB13 Step 6: In the sixth blank box, enter your Social Security number.

Alabama Provider Screening Form IB13 Step 7: In the seventh blank box, enter your date of birth.

Alabama Provider Screening Form IB13 Step 8: In the eighth blank box, enter your daytime telephone number.

Alabama Provider Screening Form IB13 Step 9: Indicate your race or ethnicity with a check mark.

Alabama Provider Screening Form IB13 Step 10: Indicate with a check mark whether you have or have been told you have high cholesterol, high blood pressure or diabetes.

Alabama Provider Screening Form IB13 Step 11: Indicate with a check mark whether you take any medication for the conditions listed in step 10.

Alabama Provider Screening Form IB13 Step 12: The second section should be completed by your health care provider. They will detail your blood pressure, total cholesterol, HDL and LDL cholesterol, triglycerides, blood glucose, height, weight, body mass index, waist measurement, and waist/height ratio.

Alabama Provider Screening Form IB13 Step 13: On the next blank line, the provider should print their name.

Alabama Provider Screening Form IB13 Step 14: On the next blank line, the provider should enter their signature.

Alabama Provider Screening Form IB13 Step 15: On the next blank line, the provider should enter their address.

Alabama Provider Screening Form IB13 Step 16: The completed form should be returned to the State Employees' Insurance Board at the address given at the bottom of the page.

INSTRUCTIONS: ALABAMA WELLNESS DISCOUNT CERTIFICATION FORM (Form IB07)

Alabama state employees who have participated in a worksite wellness screening and have since taken correctly documented steps to control identified health risks may apply for a wellness premium discount on their health insurance coverage by filing a form IB07. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

Alabama Wellness Discount Certification Form IB07 Step 1: In the first blank box, enter the member name.

Alabama Wellness Discount Certification Form IB07 Step 2: In the second blank box, indicate with a check mark whether you are male or female.

Alabama Wellness Discount Certification Form IB07 Step 3: In the third blank box, enter your age.

Alabama Wellness Discount Certification Form IB07 Step 4: In the fourth blank box, enter your contract number.

Alabama Wellness Discount Certification Form IB07 Step 5: In the fifth blank box, enter your Social Security number.

Alabama Wellness Discount Certification Form IB07 Step 6: In the sixth blank box, enter your date of birth.

Alabama Wellness Discount Certification Form IB07 Step 7: In the seventh blank box, enter your daytime telephone number, including the area code.

Alabama Wellness Discount Certification Form IB07 Step 8: Check the first box if you were counseled by a health provider. You must attach either a wellness program office visit referral or a completed provider screening form documenting results. Indicate which with a check mark.

Alabama Wellness Discount Certification Form IB07 Step 9: Check the fourth box if you participated in a Physician Supervised Weight Management program. Enter the name and phone number of the program and the dates on which you attended.

Alabama Wellness Discount Certification Form IB07 Step 10: Check the fifth box if you participated in a SEIB Fitness Center's wellness program. Enter the name and phone number of the program, the dates you attended and a program description.

Alabama Wellness Discount Certification Form IB07 Step 11: Check the sixth box if you self-managed your health risks. You must attach valid proof.

Alabama Wellness Discount Certification Form IB07 Step 12: You must submit this form to the Alabama State Employees' Insurance Board no later than November 30th. Incomplete forms will not be processed and will be returned. Mail the form to the address given at the bottom of the page.

INSTRUCTIONS: ALABAMA COBRA EMPLOYER NOTICE MEMO (Form IB11)

When an Alabama state employee enrolled in the state's SEHIP retirement plan is terminated, dies, has a reduction in hours or becomes eligible for Medicare, their employer must file a form IB11. This form is available on the website maintained by the Alabama State Employees' Insurance Board. Note that instead of filing this memo, you may choose to file a form 11 instead. Further assistance may be obtained by calling the telephone number given at the bottom of the page.

Alabama COBRA Employer Notice Memo IB11 Step 1: On the first blank line, enter the name of the employee.

Alabama COBRA Employer Notice Memo IB11 Step 2: On the second blank line, enter the Social Security number of the employee.

Alabama COBRA Employer Notice Memo IB11 Step 3: On the third blank line, enter the number and street or P.O. box of the employee.

Alabama COBRA Employer Notice Memo IB11 Step 4: On the fourth blank line, enter the city, state and zip code of the employee.

Alabama COBRA Employer Notice Memo IB11 Step 5: On the fifth blank line, enter the name of the employer.

Alabama COBRA Employer Notice Memo IB11 Step 6: If the employee has been terminated for any reason other than gross misconduct, check line 1. Enter the date of their termination.

Alabama COBRA Employer Notice Memo IB11 Step 7: If the employee has had their hours reduced, including a reduction in leave without pay, check line 2. Enter the date on which the reduction took effect.

Alabama COBRA Employer Notice Memo IB11 Step 8: If the employee has died, check line 3. Enter the date of death.

Alabama COBRA Employer Notice Memo IB11 Step 9: If the employee has become eligible for Medicare, check line 4. Enter the date on which they become eligible. Note that this will only affect medical coverage. Dental, prescription or vision care coverage will remain in effect.

Alabama COBRA Employer Notice Memo IB11 Step 10: On the next blank line, enter the date.

Alabama COBRA Employer Notice Memo IB11 Step 11: On the next blank line, the employer should enter their name.

Alabama COBRA Employer Notice Memo IB11 Step 12: Mail the form to the address given at the bottom of the page. You may also fax it to the number given.