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.