INSTRUCTIONS: ALABAMA REVOKE ELECTION FORM (Form IB09)

To revoke the election of dependent coverage due to a change in status as an Alabama state employee, a form IB09 should be filed. This document is not applicable to retirees. The application can be obtained from the website maintained by the Alabama State Employees' Insurance Board.

Alabama Revoke Election Form IB09 Step 1: Print your name on the first blank line.

Alabama Revoke Election Form IB09 Step 2: Enter your contract number on the second blank line.

Alabama Revoke Election Form IB09 Step 3: Enter your work telephone number on the third blank line.

Alabama Revoke Election Form IB09 Step 4: Enter your employing agency on the fourth blank line.

Alabama Revoke Election Form IB09 Step 5: In the next section, you must indicate the reason for your change in status with a check mark. Check the first statement if you have added dependents.

Alabama Revoke Election Form IB09 Step 6: Check the second statement if you have lost dependents.

Alabama Revoke Election Form IB09 Step 7: Check the third statement if you or your spouse have taken an unpaid leave of absence.

Alabama Revoke Election Form IB09 Step 8: Check the fourth statement if your spouse or dependent have terminated or commenced employment.

Alabama Revoke Election Form IB09 Step 9: Check the fifth statement if you, your spouse or a dependent have changed your employment status from full-time to part-time or vice versa.

Alabama Revoke Election Form IB09 Step 10: Check the sixth statement if you have changed from hourly to salaried payroll status or vice versa.

Alabama Revoke Election Form IB09 Step 11: Check the seventh statement if you have experienced any other change in employment status not listed above.

Alabama Revoke Election Form IB09 Step 12: Check any of the statements listed below if applicable.

Alabama Revoke Election Form IB09 Step 13: Enter the date on which the qualifying event occurred where indicated. This event must have occurred within the last 90 days.

Alabama Revoke Election Form IB09 Step 14: Enter your signature on the next blank line.

Alabama Revoke Election Form IB09 Step 15: Enter the date on the next blank line.

Alabama Revoke Election Form IB09 Step 16: Enter your email address on the last blank line.