INSTRUCTIONS: ALABAMA NON-TOBACCO USER DISCOUNT APPLICATION (Form IB05)

Alabama state employees may apply for a discount on their state-administered health insurance if they are not tobacco users. This is done by filing a form IB05. This document can be obtained from the website maintained by the Alabama State Employees' Insurance Board.

Alabama Non-Tobacco User Discount Application IB05 Step 1: In the first blank box, print the name of the contract holder.

Alabama Non-Tobacco User Discount Application IB05 Step 2: In the second blank box, enter the Social Security number of the contract holder.

Alabama Non-Tobacco User Discount Application IB05 Step 3: In the third blank box, enter the email address of the contract holder.

Alabama Non-Tobacco User Discount Application IB05 Step 4: The first paragraph states that you are not currently using and have not used any tobacco products within the last 12 months.

Alabama Non-Tobacco User Discount Application IB05 Step 5: The second paragraph states that if you have a spouse who is covered as a dependent under your State Employees' Health Insurance Plan, they are not currently using and have not used any tobacco products within the last 12 months.

Alabama Non-Tobacco User Discount Application IB05 Step 6: The third paragraph states that if it is determined either you or your spouse has been lying about use of tobacco products, or if either spouse begins using them, they will be subject to disciplinary action, which may include termination from employment, as well as repayment of all claims and expenses incurred by the State Employees' Health Insurance Plan.

Alabama Non-Tobacco User Discount Application IB05 Step 7: The contract holder should enter their signature in the first blank line beneath the third paragraph.

Alabama Non-Tobacco User Discount Application IB05 Step 8: The date should be entered in the next blank line.

Alabama Non-Tobacco User Discount Application IB05 Step 9: The next paragraph states that you authorize doctors and all other relevant parties to discuss your use of tobacco products. Enter your signature in the next blank line.

Alabama Non-Tobacco User Discount Application IB05 Step 10: Enter the date on the next blank line.

Alabama Non-Tobacco User Discount Application IB05 Step 11: If applicable, your spouse should sign and date the next two blank lines.

Alabama Non-Tobacco User Discount Application IB05 Step 12: Return the form to the address given at the bottom of the page.