INSTRUCTIONS: ALABAMA STATE EMPLOYEES' HEALTH INSURANCE PLAN ANNUAL TOBACCO USER PREMIUM DISCOUNT APPLICATION (Form IB06)

Alabama state employees apply for a tobacco user premium discount application using a form IB06. This document can be obtained from the website maintained by the Alabama State Employees' Insurance Board.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 1: Enter the name of the contract holder in the first blank box.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 2: Enter your contract number in the second blank box.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 3: Check the first statement if you have used tobacco products in the last 12 months.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 4: Check the second statement if your spouse has used tobacco products in the last 12 months.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 5: Check the third statement if you have completed an SEIB approved tobacco cessation program and attach verification.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 6: Check the fourth statement if your spouse has completed an SEIB approved tobacco cessation program and attach verification.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 7: Check the fifth statement if you cannot stop using tobacco products as advised by your physician because it would be unreasonably difficult due to a medical condition. Attach a statement from your physician.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 8: Check the sixth statement if your spouse cannot stop using tobacco products as advised by your physician because it would be unreasonably difficult due to a medical condition. Attach a statement from your physician.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 9: Enter your signature, date and daytime phone number where indicated.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 10: Sign and date the authorization portion of the form and enter the name and telephone number of your primary care physician. If applicable, your spouse should do the same.

INSTRUCTIONS: ALABAMA SUPPLEMENTARY REPORT (WC Form 3)

As part of the process of paying workers' compensation in Alabama after an on-the-job injury, employers may be required to complete the form discussed in this article. This document can be obtained from the website of the Alabama Department of Labor.

Alabama Supplementary Report WC Form 3 Step 1: Indicate whether this form documents a first payment, reinstatement or is amended with a check mark.

Alabama Supplementary Report WC Form 3 Step 2: Enter the employee's name on line 1.

Alabama Supplementary Report WC Form 3 Step 3: Enter the employee's Social Security number on line 2.

Alabama Supplementary Report WC Form 3 Step 4: Enter the name of the employer on line 3.

Alabama Supplementary Report WC Form 3 Step 5: Enter the unemployment compensation number on line 4.

Alabama Supplementary Report WC Form 3 Step 6: Enter the date of the injury on line 5.

Alabama Supplementary Report WC Form 3 Step 7: Enter the date the disability began this period on line 6.

Alabama Supplementary Report WC Form 3 Step 8: Enter the name of the insurance carrier on line 7.

Alabama Supplementary Report WC Form 3 Step 9: Enter the claim number and service number on line 8.

Alabama Supplementary Report WC Form 3 Step 10: Enter the name, address, telephone number, and extension of the office filing this report on line 9.

Alabama Supplementary Report WC Form 3 Step 11: If payment was made, on line A, enter the date of the first check on the first blank line.

Alabama Supplementary Report WC Form 3 Step 12: Enter the amount of the first check on the second blank line.

Alabama Supplementary Report WC Form 3 Step 13: Enter the period covered by the first check on the third blank line.

Alabama Supplementary Report WC Form 3 Step 14: Enter the average weekly wage on the fourth blank line.

Alabama Supplementary Report WC Form 3 Step 15: Enter the compensation rate per week on the fifth blank line.

Alabama Supplementary Report WC Form 3 Step 16: If compensation was not paid within 30 days from the date on which the disability began, complete Part B. Indicate the reason for non-payment on line 13. On line 14, indicate whether compensation was denied and the claimant notified.

INSTRUCTIONS: ARIZONA VERIFICATION RECORD (Form 71-1009)

As part of the bingo licensing process in Arizona, a form 71-1009 is used to document each game. This form can be obtained from the website of the Arizona Department of Revenue.

Arizona Verification Record 71-1009 Step 1: Section A concerns the occasion. Enter the date, the license number, the number of players and the supervisor for the occasion.

Arizona Verification Record 71-1009 Step 2: Section B concerns card sales. For each such transaction, enter the item number, price, number sold, total income and wastage cards. Enter the total card sales at the bottom of the table provided.

Arizona Verification Record 71-1009 Step 3: Section C concerns supply sales. For each dauber, glue stick or other sold, enter the number sold, price and income. Enter the total supply sales at the bottom of the table provided.

Arizona Verification Record 71-1009 Step 4: Section D concerns inducements. Document your giveaways, discounts, admission fees, card sales, supply sales, gross receipts, cash payouts, remaining receipts, beginning cash, cash on hand, cash short or cash over, bank deposit and ending cash as instructed.

Arizona Verification Record 71-1009 Step 5: Section E concerns adjusted gross receipts. Enter your total income on the first blank line and the total prize money on the second blank line.

Arizona Verification Record 71-1009 Step 6: Subtract the second blank line from the first blank line and enter the resulting difference on the third blank line. This is your adjusted income.

Arizona Verification Record 71-1009 Step 7: The supervisor should enter their signature on the first blank line.

Arizona Verification Record 71-1009 Step 8: A witness should enter their signature on the second blank line.

Arizona Verification Record 71-1009 Step 9: The date the form was completed should be entered on the third blank line.

Arizona Verification Record 71-1009 Step 10: Enter any miscellaneous information at the bottom of the first page.

Arizona Verification Record 71-1009 Step 11: The two tables provided at the top of the second page require you to document legend items.

Arizona Verification Record 71-1009 Step 12: The two tables provided at the bottom of the second page are game worksheets. For each game, enter its number, the item number, the cost of each, the number sold, the total income and the prize. 

INSTRUCTIONS: CONNECTICUT INSURANCE PREMIUM FINANCE COMPANY LICENSE RENEWAL APPLICATION

To renew your Connecticut license to act as an insurance premium finance company, you must file the application discussed in this article. This document can be obtained from the website maintained by the government of Connecticut.

Connecticut Insurance Premium Finance Company License Renewal Application Step 1: Enter the company name on the first blank line.

Connecticut Insurance Premium Finance Company License Renewal Application Step 2: Enter the company address on the second blank line.

Connecticut Insurance Premium Finance Company License Renewal Application Step 3: Enter the name of a contact person on the third blank line.

Connecticut Insurance Premium Finance Company License Renewal Application Step 4: Enter a contact phone number on the fourth blank line.

Connecticut Insurance Premium Finance Company License Renewal Application Step 5: Enter the company federal tax identification number on the fifth blank line.

Connecticut Insurance Premium Finance Company License Renewal Application Step 6: On line 1, indicate with a check mark whether the company has employees in Connecticut. If yes, you must attach a current certificate of worker's compensation insurance.

Connecticut Insurance Premium Finance Company License Renewal Application Step 7: Line 2 requires you to make a financial statement about the current financial condition of your company. Enter the date, your assets, liabilities, surplus and the total of your liabilities and surplus where indicated.

Connecticut Insurance Premium Finance Company License Renewal Application Step 8: Line 3 should be completed if your partnership, association or corporation has experienced changes in its partners, members or officers. Enter the full name of each new partner member or officer, their title (if they are an officer), their residential address, their business address and their occupation.

Connecticut Insurance Premium Finance Company License Renewal Application Step 9: Line 4 should completed if your corporation has experienced changes in directors. Enter the full name of each new director, their title (if an officer), their residential address, their business address and their occupation.

Connecticut Insurance Premium Finance Company License Renewal Application Step 10: If you have any new partners, directors, members or officers listed on lines 4 or 5, you must complete a separate biographical affidavit for each one. This is located on the third page.

Connecticut Insurance Premium Finance Company License Renewal Application Step 11: Sign and date the second page before a notary public.

INSTRUCTIONS: CONNECTICUT ADDENDUM TO IDENTIFY ALL PROVIDER NETWORKS CONTRACTED WITH MANAGED CARE ORGANIZATIONS

Connecticut organizations use the form discussed in this article to identify all provider networks which are contracted with managed care. This document can be obtained from the website maintained by the government of Connecticut.

Connecticut Addendum To Identify All Provider Networks Contracted With Managed Care Organizations Step 1: Enter your network name on the first blank line.

Connecticut Addendum To Identify All Provider Networks Contracted With Managed Care Organizations Step 2: Enter your network address on the next two blank lines.

Connecticut Addendum To Identify All Provider Networks Contracted With Managed Care Organizations Step 3: Enter a contact name for your network on the fourth blank line.

Connecticut Addendum To Identify All Provider Networks Contracted With Managed Care Organizations Step 4: Enter a phone number for your network on the fifth blank line.

Connecticut Addendum To Identify All Provider Networks Contracted With Managed Care Organizations Step 5: Enter the effective date of your current contract on the sixth blank line.

Connecticut Addendum To Identify All Provider Networks Contracted With Managed Care Organizations Step 6: Enter the contract renewal date on the seventh blank line.

Connecticut Addendum To Identify All Provider Networks Contracted With Managed Care Organizations Step 7: If the network is a licensed preferred provider network in Connecticut, enter its state license number on the eighth blank line.

Connecticut Addendum To Identify All Provider Networks Contracted With Managed Care Organizations Step 8: On line 1, place a check mark next to all types of services provided by this network.

Connecticut Addendum To Identify All Provider Networks Contracted With Managed Care Organizations Step 9: On line 2, indicate with a check mark whether or not the network is owned and operated by the managed care organization. If yes, indicate with a check mark whether the network provides services to Connecticut enrollees of other health plans.

Connecticut Addendum To Identify All Provider Networks Contracted With Managed Care Organizations Step 10: On line 3, indicate with a check mark whether the managed care organization makes payments to the network, which distributes them to participating providers, or whether payments are made directly to individual network providers.

Connecticut Addendum To Identify All Provider Networks Contracted With Managed Care Organizations Step 11: Answer questions 4 through 7 as instructed. 

INSTRUCTIONS: CONNECTICUT CERTIFICATE OF CLOSED PROCEEDINGS (Form JD-CV-11)

When pleadings have closed in a Connecticut case, a form JC-CV-11 should be completed. This document can be obtained from the website maintained by the Connecticut Judicial Branch.

Connecticut Certificate Of Closed Proceedings JD-CV-11 Step 1: Enter the case docket number in the first blank box.

Connecticut Certificate Of Closed Proceedings JD-CV-11 Step 2: Enter the name of the case in the second blank box.

Connecticut Certificate Of Closed Proceedings JD-CV-11 Step 3: In the third blank box, indicate with a check mark whether the case is being heard in a judicial district, housing sessions or geographical area number court. If the latter, give its number.

Connecticut Certificate Of Closed Proceedings JD-CV-11 Step 4: In the fourth blank box, give the address of the court.

Connecticut Certificate Of Closed Proceedings JD-CV-11 Step 5: In the fifth blank box, enter the name of the person completing this form.

Connecticut Certificate Of Closed Proceedings JD-CV-11 Step 6: In the sixth blank box, enter your signature.

Connecticut Certificate Of Closed Proceedings JD-CV-11 Step 7: In the seventh blank box, indicate with a check mark whether the person completing the form is the plaintiff, their attorney, the defendant or their attorney.

Connecticut Certificate Of Closed Proceedings JD-CV-11 Step 8: The next section requires you to indicate how the case will proceed. Place an "X" next to all applicable statements.

Connecticut Certificate Of Closed Proceedings JD-CV-11 Step 9: Section A should only be completed if the case is privileged. If so, place an "X" next to all statements which are the basis of this privilege.

Connecticut Certificate Of Closed Proceedings JD-CV-11 Step 10: Section B concerns the relief being requested. Place an "X" in the first box if seeking $15,000 or more.

Connecticut Certificate Of Closed Proceedings JD-CV-11 Step 11: Place an "X" in the second box if seeking less than $15,000.

Connecticut Certificate Of Closed Proceedings JD-CV-11 Step 12: Place an "X" in the third box if claiming other relief in addition to or instead of monetary damages.

Connecticut Certificate Of Closed Proceedings JD-CV-11 Step 13: The bottom portion of the form should be completed to certify that copies of this document have been mailed or delivered electronically or non-electronically to all attorneys and self-represented parties involved in this case. 

INSTRUCTIONS: CONNECTICUT NOTICE OF JUDGMENT AND ORDER FOR WEEKLY PAYMENTS (Form JD-CV-50)

In a Connecticut case involving creditors and debtors, a form JD-CV-50 is used to render judgment and order the defendant to make weekly payments. This document can be found on the website of the Connecticut Judicial Branch.

Connecticut Notice Of Judgment And Order For Weekly Payments JD-CV-50 Step 1: Section I is for completion by the plaintiff or their attorney. If the case occurred in a judicial district court, check the first box.

Connecticut Notice Of Judgment And Order For Weekly Payments JD-CV-50 Step 2: If the case occurred in a housing session court, check the second box.

Connecticut Notice Of Judgment And Order For Weekly Payments JD-CV-50 Step 3: If the case occurred in a Geographic Area Number court, check the box and enter the number.

Connecticut Notice Of Judgment And Order For Weekly Payments JD-CV-50 Step 4: Enter the address of the court, including the street number and name, town name and zip code.

Connecticut Notice Of Judgment And Order For Weekly Payments JD-CV-50 Step 5: Enter the name of the case.

Connecticut Notice Of Judgment And Order For Weekly Payments JD-CV-50 Step 6: Enter the names of all defendants who must pay judgment.

Connecticut Notice Of Judgment And Order For Weekly Payments JD-CV-50 Step 7: Section II is for completion by the court clerk. On line 1, the amount due on claims will be entered.

Connecticut Notice Of Judgment And Order For Weekly Payments JD-CV-50 Step 8: On line 2, the amount of interest due will be entered.

Connecticut Notice Of Judgment And Order For Weekly Payments JD-CV-50 Step 9: On line 3, the amount of reasonable attorney's fees due will be entered. On line 4, the amount due for other reasonable charges will be entered.

Connecticut Notice Of Judgment And Order For Weekly Payments JD-CV-50 Step 10: Add lines 1 through 4. Enter the resulting sum on line 5. On line 6, the plaintiff's costs will be entered. This will be added to line 5 and the resulting amount due entered on line 7.

Connecticut Notice Of Judgment And Order For Weekly Payments JD-CV-50 Step 11: The weekly payments due will be entered below. Section III will be completed once copies of this form have been delivered to all involved self-represented parties and attorneys.

INSTRUCTIONS: CONNECTICUT ANSWER TO COMPLAINT CIVIL CASES ONLY (Form JD-CV-106)

When a civil lawsuit is filed against you in Connecticut, you should file two documents in response. Form JC-DL-12 should be filed to be informed of all upcoming court dates. Form JD-CV-106 is used to respond to the numbered allegations in the complaint against you. This form can be found on the website maintained by the Connecticut Judicial Branch.

Connecticut Answer To Complaint Civil Cases Only JD-CV-106 Step 1: Enter the name of the case in the first blank box.

Connecticut Answer To Complaint Civil Cases Only JD-CV-106 Step 2: In, the second blank box, indicate with a check mark whether the case concerns a judicial district, a housing session, or property at a specific geographic location. If the latter, give its area number.

Connecticut Answer To Complaint Civil Cases Only JD-CV-106 Step 3: In the third blank box, enter the address of the court.

Connecticut Answer To Complaint Civil Cases Only JD-CV-106 Step 4: On lines 1 through 8, you may respond to the corresponding numbered allegations in the complaint filed against you. Check "Agree," "Disagree" or "Do Not Know" as applicable.

Connecticut Answer To Complaint Civil Cases Only JD-CV-106 Step 5: In the blank section provided below, write any special defenses you have.

Connecticut Answer To Complaint Civil Cases Only JD-CV-106 Step 6: Enter your signature in the next blank box.

Connecticut Answer To Complaint Civil Cases Only JD-CV-106 Step 7: Enter the date in the next blank box.

Connecticut Answer To Complaint Civil Cases Only JD-CV-106 Step 8: The paragraph below states that a copy of this document has been mailed or delivered electronically or non-electronically to all attorneys and self-represented parties of record. Enter the date on which you took this step.

Connecticut Answer To Complaint Civil Cases Only JD-CV-106 Step 9: Enter the name and address of each party and attorney to whom a copy of this document was delivered. If necessary for full documentation, attach additional sheets.

Connecticut Answer To Complaint Civil Cases Only JD-CV-106 Step 10: In the next three blank boxes, sign and print your name, as well as entering the date.

Connecticut Answer To Complaint Civil Cases Only JD-CV-106 Step 11: In the last two blank boxes, enter your mailing address and telephone number.