INSTRUCTIONS: ALABAMA STATE EMPLOYEES' HEALTH INSURANCE PLAN WELLNESS DISCOUNT CERTIFICATION FORM (Form IB07)

Alabama state employees use form IB07 to obtain a wellness discount certification after participating in a worksite wellness screening and completing one of the requirements to reduce health risks. This document can be obtained from the website maintained by the Alabama State Employees' Insurance Board.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 1: Print your name in the first blank box.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 2: Indicate whether you are male or female with a check mark.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 3: Enter your age in the second blank box.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 4: Enter your contract number in the third blank box.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 5: Enter your Social Security number in the fourth blank box.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 6: Enter your date of birth in the fifth blank box.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 7: Enter your daytime phone number, including the area code, in the sixth blank box.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 8: Check the first statement if you were counseled by your health care provider about the health risks identified in your wellness screening results and are attaching either a Wellness Program Office Visit Referral or a Completed Provider Screening Form. Indicate which with a check mark.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 9: Check the second statement if you participated in a Physician Supervised Weight Management program. Enter the name and phone number of the program and the dates you attended.

Alabama State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 10: Check the third statement 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 State Employees' Health Insurance Plan Wellness Discount Certification Form IB07 Step 11: Check the fourth statement if you are self-managing your health risks and attach valid proof.

INSTRUCTIONS: ALABAMA PEEHIP HEALTH INSURANCE AND OPTIONAL STATUS CHANGE 

Alabama public employees enrolled in the state-administered health insurance plan use the document discussed in this article to make an optional status change. This document can be obtained from the website maintained by the Retirement Systems of Alabama.

Alabama PEEHIP Health Insurance And Optional Status Change Step 1: Indicate whether you are an active or retired member with a check mark.

Alabama PEEHIP Health Insurance And Optional Status Change Step 2: The first section concerns the subscriber. On the first line, enter your Social Security number or PiD number, first name, middle name or initial and last name.

Alabama PEEHIP Health Insurance And Optional Status Change Step 3: On the second line, enter your date of birth and daytime phone number, as well as indicating your marital status with a check mark.

Alabama PEEHIP Health Insurance And Optional Status Change Step 4: On the third line, indicate with a check mark whether you or your spouse have used tobacco products in the last 12 months.

Alabama PEEHIP Health Insurance And Optional Status Change Step 5: In the next two blank boxes, if you have changed names, enter your previous full name and new full name.

Alabama PEEHIP Health Insurance And Optional Status Change Step 6: In the next blank box, if you have changed jobs, enter your date of employment transfer.

Alabama PEEHIP Health Insurance And Optional Status Change Step 7: In the next section, indicate the type of coverage change you wish to make by placing a check mark next to the applicable statement. Enter your requested effective date at the bottom of this section.

Alabama PEEHIP Health Insurance And Optional Status Change Step 8: In the next section, indicate the reasons for these changes by checking all applicable statements.

Alabama PEEHIP Health Insurance And Optional Status Change Step 9: The next section concerns dependents and is only required for family coverage.

Alabama PEEHIP Health Insurance And Optional Status Change Step 10: The next section at the top of the second page must be completed if the member elects the PEEHIP supplemental plan or if the member or their dependents have other group health, dental or vision coverage currently in effect.

Alabama PEEHIP Health Insurance And Optional Status Change Step 11: Provide all other information requested. Sign and date the bottom of the form.

INSTRUCTIONS: ARIZONA ENDORSEMENT BY LOCAL GOVERNING BODY (Form 71-1002)

As part of the Arizona bingo license application process, a form 71-1002 must be submitted documenting endorsement from your local governing body. This document can be obtained from the website of the Arizona Department of Revenue.

Arizona Endorsement By Local Governing Body 71-1002 Step 1: Indicate with a check mark if this is a new application or one documenting a change of location.

Arizona Endorsement By Local Governing Body 71-1002 Step 2: In the first two blank boxes, enter your license number and the date.

Arizona Endorsement By Local Governing Body 71-1002 Step 3: In the next blank box, enter the name of the local governing body.

Arizona Endorsement By Local Governing Body 71-1002 Step 4: In the next blank box, enter the street number or P.O. box of the local governing body.

Arizona Endorsement By Local Governing Body 71-1002 Step 5: In the next blank box, enter the telephone number of the local governing body.

Arizona Endorsement By Local Governing Body 71-1002 Step 6: In the next blank box, enter the city, state and zip code of the local governing body.

Arizona Endorsement By Local Governing Body 71-1002 Step 7: On line 1, enter the date on which your hearing was conducted.

Arizona Endorsement By Local Governing Body 71-1002 Step 8: Indicate with a check mark whether the hearing concerned a hearing for a bingo license or for a bingo license location transfer.

Arizona Endorsement By Local Governing Body 71-1002 Step 9: On line 2, enter the name of the applicant.

Arizona Endorsement By Local Governing Body 71-1002 Step 10: On line 3, enter the location or address where games will be conducted.

Arizona Endorsement By Local Governing Body 71-1002 Step 11: On line 4, enter the days and times on which games will be conducted.

Arizona Endorsement By Local Governing Body 71-1002 Step 12: On line 5, indicate with a check mark whether background investigations have been conducted on all individuals listed on the Bingo License Application.

Arizona Endorsement By Local Governing Body 71-1002 Step 13: On line 6, indicate with a check mark whether you recommend the application be approved or disapproved.

Arizona Endorsement By Local Governing Body 71-1002 Step 14: On line 7, enter any specific reasons you have for your recommendation. Sign and date the form where indicated.

INSTRUCTIONS: CONNECTICUT SURPLUS LINES AFFIDAVIT (Form SL-8)

To document Connecticut surplus lines, use a form SL-8. This document can be obtained from the website maintained by the government of Connecticut.

Connecticut Surplus Lines Affidavit SL-8 Step 1: Enter the name and address of the surplus lines broker on line 1.

Connecticut Surplus Lines Affidavit SL-8 Step 2: Enter the name of the producing agency on line 2.

Connecticut Surplus Lines Affidavit SL-8 Step 3: Enter the Connecticut license number of the producing agency on line 2a.

Connecticut Surplus Lines Affidavit SL-8 Step 4: Enter the agency represented on line 3.

Connecticut Surplus Lines Affidavit SL-8 Step 5: Enter the Connecticut license number of the agency represented on line 3a.

Connecticut Surplus Lines Affidavit SL-8 Step 6: Enter the name and location on the risk on line 4.

Connecticut Surplus Lines Affidavit SL-8 Step 7: Enter surplus lines insurers and their NAIC number on lines 5a and 5b.

Connecticut Surplus Lines Affidavit SL-8 Step 8: Enter the name of the associated representative on line 5c.

Connecticut Surplus Lines Affidavit SL-8 Step 9: Enter the kind of insurance on line 6.

Connecticut Surplus Lines Affidavit SL-8 Step 10: Enter the limits on line 6a.

Connecticut Surplus Lines Affidavit SL-8 Step 11: Enter the risk description on line 6b.

Connecticut Surplus Lines Affidavit SL-8 Step 12: Indicate whether this is a new business policy or renewal on line 7 with a check mark.

Connecticut Surplus Lines Affidavit SL-8 Step 13: Enter the reasons for placement on line 7b.

Connecticut Surplus Lines Affidavit SL-8 Step 14: Enter the premium on line 8.

Connecticut Surplus Lines Affidavit SL-8 Step 15: Indicate whether this is a term premium, installment or subject to audit with a check mark on line 8a.

Connecticut Surplus Lines Affidavit SL-8 Step 16: Enter the policy period on line 8b.

Connecticut Surplus Lines Affidavit SL-8 Step 17: On line 9, indicate with a check mark whether the broker completing this form has on file evidence of declination by three licensed insurers and ineligibility for any residential market mechanism.

Connecticut Surplus Lines Affidavit SL-8 Step 18: Enter the broker service fee on line 9a and the producer service fee on line 9b.

Connecticut Surplus Lines Affidavit SL-8 Step 19: The insured should sign the form in the presence of a notary public.

INSTRUCTIONS: CONNECTICUT ANNUAL PEO CERTIFICATION 

In Connecticut, companies which outsource human resources and health insurance responsibilities to a professional employer organization (PEO) are required to file an annual certification regarding this. The document discussed in this article can be obtained from the website maintained by the government of the state of Connecticut.

Connecticut Annual PEO Certification Step 1: On the first blank line, enter the name of the company. A separate form must be submitted for each company name.

Connecticut Annual PEO Certification Step 2: On the second blank line, enter the company address.

Connecticut Annual PEO Certification Step 3: On the third blank line, enter the NAIC number of the company.

Connecticut Annual PEO Certification Step 4: The next section requires you to list all professional employer organizations for which the company is providing a large group health insurance product. Where indicated, enter the name of each professional employer organization.

Connecticut Annual PEO Certification Step 5: For each professional employer organization, indicate with a check mark whether it is fully integrated.

Connecticut Annual PEO Certification Step 6: For each professional employer organization, indicate with a check mark whether they have submitted certification with the application for coverage which they have achieved and will continue to maintain throughout the term of the underlying insurance policy fully integrated co-employer status with each participant enrolled under the contract.

Connecticut Annual PEO Certification Step 7: The next section requires you to list all professional employer organizations for which the company is providing large group self-funded administration. Enter the name of all such organizations where indicated.

Connecticut Annual PEO Certification Step 8: Indicate whether every professional employer organization listed here is fully integrated with a check mark where indicated.

Connecticut Annual PEO Certification Step 9: Indicate with a check mark whether every professional employer organization listed here has submitted certification with the application for coverage that they have achieved and will continue to maintain throughout the term of the underlying insurance policy fully integrated co-employer status with each participant enrolled under the contract.

Connecticut Annual PEO Certification Step 10: On the second page, an officer of the organization should print their name on the first blank line, enter their title on the second blank line, and enter the name of their company or organization on the third blank line. Sign and date the form where indicated.

INSTRUCTIONS: CONNECTICUT SELF-FUNDED CANDIDATE'S EXPENDITURE STATEMENT (SEEC Form 23)

Self-funded Connecticut candidates use a SEEC form 23 in order to document their expenditures. This document can be obtained from the website of the government of Connecticut. Detailed further instructions for completion of this form can be obtained from the website of the Connecticut State Elections Enforcement Commission or in person from their offices.

Connecticut Self-Funded Candidate's Expenditure Statement SEEC Form 23 Step 1: On line 1, enter the candidate's first name, middle initial, last name and suffix.

Connecticut Self-Funded Candidate's Expenditure Statement SEEC Form 23 Step 2: On line 2, enter the candidate's street address, city, state and zip code.

Connecticut Self-Funded Candidate's Expenditure Statement SEEC Form 23 Step 3: On line 3, enter the election date.

Connecticut Self-Funded Candidate's Expenditure Statement SEEC Form 23 Step 4: On line 4, enter the office sought.

Connecticut Self-Funded Candidate's Expenditure Statement SEEC Form 23 Step 5: On line 5, enter the district number, if applicable.

Connecticut Self-Funded Candidate's Expenditure Statement SEEC Form 23 Step 6: Indicate the type of report being filed with a check mark on line 6.

Connecticut Self-Funded Candidate's Expenditure Statement SEEC Form 23 Step 7: On line 7, enter the beginning and ending dates of the period being covered.

Connecticut Self-Funded Candidate's Expenditure Statement SEEC Form 23 Step 8: On line 8, the candidate should print and sign their name, as well as providing the date.

Connecticut Self-Funded Candidate's Expenditure Statement SEEC Form 23 Step 9: On line 9, expenditures paid by the candidate should be documented. To do so, you must first complete Section A on the second page. Supplemental pages are provided if you require more space for documentation. Note that when completing lines 9 through 11, enter the applicable figure for the period being documented in Column A and the aggregate applicable figure in Column B.

Connecticut Self-Funded Candidate's Expenditure Statement SEEC Form 23 Step 10: On line 10, expenditures incurred by the candidate this period but not paid should be documented. To do so, you must first complete Section B on the third page.

Connecticut Self-Funded Candidate's Expenditure Statement SEEC Form 23 Step 11: On line 11, total outstanding expenditures incurred by the candidate but still unpaid should be documented. To do so, you must first complete Section B on the third page.

INSTRUCTIONS: CONNECTICUT NOTICE OF APPLICATION FOR PREJUDGMENT REMEDY/CLAIM FOR HEARING TO CONTEST APPLICATION OR CLAIM EXEMPTION (Form JD-CV-53)

When applying for a prejudgment remedy as a plaintiff creditor in a Connecticut case, a notice of application should be filed. This form JD-CV-53 can also be used by the debtor, once they are served with it, to contest the application or claim an exemption. This document can be obtained from the website of the Connecticut Judicial Branch.

Connecticut Notice Of Application For Prejudgment Remedy/Claim For Hearing To Contest Application Or Claim Exemption JD-CV-53 Step 1: Indicate whether you are being heard in a judicial district court, a housing session court, or a G.A. court in the first blank box. Enter the court's address in the second blank box.

Connecticut Notice Of Application For Prejudgment Remedy/Claim For Hearing To Contest Application Or Claim Exemption JD-CV-53 Step 2: Indicate with a check mark whether a temporary restraining order has been requested.

Connecticut Notice Of Application For Prejudgment Remedy/Claim For Hearing To Contest Application Or Claim Exemption JD-CV-53 Step 3: Indicate whether this is a major or minor case and enter the number of counts.

Connecticut Notice Of Application For Prejudgment Remedy/Claim For Hearing To Contest Application Or Claim Exemption JD-CV-53 Step 4: Indicate the amount of prejudgment you are seeking by checking the box next to the appropriate range.

Connecticut Notice Of Application For Prejudgment Remedy/Claim For Hearing To Contest Application Or Claim Exemption JD-CV-53 Step 5: Enter the name and address of the plaintiff.

Connecticut Notice Of Application For Prejudgment Remedy/Claim For Hearing To Contest Application Or Claim Exemption JD-CV-53 Step 6: Enter the name, address and telephone number of defendants against whom remedy is being sought.

Connecticut Notice Of Application For Prejudgment Remedy/Claim For Hearing To Contest Application Or Claim Exemption JD-CV-53 Step 7: Enter the name and address of third parties holding defendant property subject to garnishing.

Connecticut Notice Of Application For Prejudgment Remedy/Claim For Hearing To Contest Application Or Claim Exemption JD-CV-53 Step 8: The plaintiff or their attorney should provide their name, address, telephone number, juris number (if applicable), signature and the date. 

Connecticut Notice Of Application For Prejudgment Remedy/Claim For Hearing To Contest Application Or Claim Exemption JD-CV-53 Step 9: The defendant should complete Section III to respond to this request.

INSTRUCTIONS: CONNECTICUT CONSENT OF PARTIES TO REFERRAL TO JUDGE TRIAL REFEREE — CIVIL MATTERS — FOR TRIAL, JUDGMENT AND APPEAL (Form JD-CV-111)

If two parties involved in a Connecticut case concerning civil matters agree, they may file a form JD-CV-111 consenting to having their case heard by a judge trial referee. This document can be obtained from the website maintained by the Connecticut Judicial Branch.

Connecticut Consent Of Parties To Referral To Judge Trial Referee — Civil Matters — For Trial, Judgment And Appeal JD-CV-111 Step 1: In the first blank box, enter the name of the case.

Connecticut Consent Of Parties To Referral To Judge Trial Referee — Civil Matters — For Trial, Judgment And Appeal JD-CV-111 Step 2: In the second blank box, enter the docket number.

Connecticut Consent Of Parties To Referral To Judge Trial Referee — Civil Matters — For Trial, Judgment And Appeal JD-CV-111 Step 3: In the third blank box, enter the number, street, town and zip code of the judicial district.

Connecticut Consent Of Parties To Referral To Judge Trial Referee — Civil Matters — For Trial, Judgment And Appeal JD-CV-111 Step 4: The first numbered paragraph concerns the requirement of consent before the case can be transferred to a judge trial misfire.

Connecticut Consent Of Parties To Referral To Judge Trial Referee — Civil Matters — For Trial, Judgment And Appeal JD-CV-111 Step 5: The second numbered paragraph concerns requirements regarding civil jury cases.

Connecticut Consent Of Parties To Referral To Judge Trial Referee — Civil Matters — For Trial, Judgment And Appeal JD-CV-111 Step 6: The third numbered paragraph concerns circumstances under which consent is not required for this kind of referral.

Connecticut Consent Of Parties To Referral To Judge Trial Referee — Civil Matters — For Trial, Judgment And Appeal JD-CV-111 Step 7: The next section of the form requires the signatures of all involved parties. Plaintiffs should enter their name in the first column of the top half of this table, their signature in the second column and the print name of the person signing in the third column. 

Connecticut Consent Of Parties To Referral To Judge Trial Referee — Civil Matters — For Trial, Judgment And Appeal JD-CV-111 Step 8: Defendants should also provide their names, signatures and print names of the person signing in the bottom of the table.