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.

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.

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.