INSTRUCTIONS: ALABAMA REVOKE ELECTION FORM STATE EMPLOYEES' HEALTH INSURANCE COVERAGE (Form IB09)

To cancel dependent coverage included in Alabama state employees' health insurance coverage, a form IB09 should be used. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 1: Print your name on the first blank line.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 2: Enter your contract number on the second blank line.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 3: Enter your work telephone number on the third blank line.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 4: Enter your agency name on the fourth blank line.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 5: Check the line next to the first statement if you have added dependents through marriage, birth or adoption of a child. Check the line next to the second statement if you have lost dependents.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 6: The next five statements concern various changes in the employment status of you or your spouse. Check the line next to any applicable statements.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 7: Check the next line if the dependant has lost coverage due to their age.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 8: Check the next line if you are documenting a change of residence or worksite.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 9: Check the next line if you are complying with a family relations judgment, decree or order.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 10: Check the next line if revoking coverage due to a Medicare or Medicaid entitlement.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 11: Check the next line if taking leave under the Family and Medical Leave act.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 12: Check any of the next three lines if applicable.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 13: On the next blank line, enter the date on which the qualifying event occurred. Sign and date the bottom of the page.