Sample Certificate Of Creditable Coverage printable pdf download

Sample Certificate Of Creditable Coverage

Sample Certificate of Creditable Coverage

Certificate of Group Health Plan Coverage

This certificate provides evidence of your prior health coverage. You may need

to furnish this certificate if you become eligible under a group health plan that

excludes coverage for certain medical conditions that you have before you enroll.

If you become covered under another group health plan, check with the plan

administrator to see if you need to provide this certificate. You may also need

this certificate to buy, for yourself or your family, an insurance policy that does

not exclude coverage for medical conditions that are present before you enroll.

1. Date of this certificate:

2. Name of group health plan:

3. Name of participant:

4. Identification number of participant:

5. Name of any dependents to whom this certificate applies:

6. Name, address, and telephone number of plan administrator or issuer

responsible for providing this certificate:

7. For further information, call:

8. If the individual(s) identified in line 3 and line 5 has at least 18 months of

creditable coverage (disregarding periods of coverage before a 63-day

break), check here _____ and skip lines 9 and 10.

9. Date waiting period or affiliation period (if any) began:

10. Date coverage began:

11. Date coverage ended: _________ (or check if coverage is continuing as of

the date of this certificate: __________ ).

Sample Certificate Of Creditable Coverage