INSTRUCTIONS: ALABAMA ANNUAL TOBACCO USER PREMIUM DISCOUNT APPLICATION (Form IB06)
Alabama state employees who are tobacco users apply for a premium on their insurance using a form IB06. This document can be obtained from the website of the Alabama State Employees' Insurance Board.
Alabama Annual Tobacco User Premium Discount Application IB06 Step 1: In the first blank box, enter the name of the contract holder.
Alabama Annual Tobacco User Premium Discount Application IB06 Step 2: In the second blank box, enter the contract number.
Alabama Annual Tobacco User Premium Discount Application IB06 Step 3: Check the first box if you have used tobacco products in the last 12 months.
Alabama Annual Tobacco User Premium Discount Application IB06 Step 4: Check the second box if your spouse has used tobacco products in the last 12 months and is covered as a dependent under SEHIP.
Alabama Annual Tobacco User Premium Discount Application IB06 Step 5: Check the third box if you have completed a SEIB approved tobacco cessation program. Verification must be attached.
Alabama Annual Tobacco User Premium Discount Application IB06 Step 6: Check the fourth box if your spouse has completed a SEIB approved tobacco cessation program. Verification must be attached.
Alabama Annual Tobacco User Premium Discount Application IB06 Step 7: Check the fifth box if your spouse cannot stop using tobacco products because it would be unreasonably difficult due to a medical condition. A statement must be attached from a physician.
Alabama Annual Tobacco User Premium Discount Application IB06 Step 8: On the first blank line, the contract holder should enter their signature.
Alabama Annual Tobacco User Premium Discount Application IB06 Step 9: On the second blank box, the date should be entered.
Alabama Annual Tobacco User Premium Discount Application IB06 Step 10: On the third blank line, the contract holder should enter their daytime phone number.
Alabama Annual Tobacco User Premium Discount Application IB06 Step 11: By completing the next section, you are authorizing physicians and other parties to speak to the State Employees' Insurance Board about your tobacco use. On the first two blank lines of this section, enter your signature and the date.
Alabama Annual Tobacco User Premium Discount Application IB06 Step 12: On the next two blank lines, your primary care physician should sign the form and enter their telephone number.