Group Attestation Form - Healthpass printable pdf download

Group Attestation Form

Regarding Total Number of Employees

As part of your HealthPass New York open enrollment, it is required that you complete this Group Attestation form.

Please complete and submit the Group Attestation in addition to enrollment paperwork and tax documents.

__________________________________________________________________________________________

Company Name/ DBA

Federal Tax ID #/ HealthPass Group ID #

A. Group Size Rating

1. Please indicate the total number of employees in each classification below, including those who work outside of

HealthPass’ coverage area.*

Employee Classification

Employee Counts

(Please provide the total number of employees regardless of

eligibility, work location or other medical coverage)

Full-Time**

Part-Time

Other***

Total Employees Eligible for Coverage with HealthPass

B. Medicare Coordination of Benefits

1. Has your group had 20 or more part-time or full-time employees for each working day in each of 20 or more

calendar weeks in the current calendar year?* Yes_____________ No___________ If no, please complete the

Small Employer Exception Certification.

1a. Or the preceding calendar year? Yes_____________ No_____________

2. Has your group had 50 or more part-time or full-time employees on 50% or more of its regular business days in

the previous calendar year? Yes_____________ No_____________

C. COBRA

1. How many employees are currently active with COBRA? _____________

2. Does your group self-administer COBRA? Yes_____________ No_____________

D. Signature

I hereby certify that the information contained herein for the period _____________(indicate policy year), is

accurate, complete and truthful. I understand and agree that any misrepresentation concerning this information will

constitute a breach of agreement with HealthPass and will result in the immediate termination of my group’s policy.

Signature

________________________________ Date ___________________________________

Print Name ________________________________ Title ____________________________________

HealthPass’ service areas are NYC (5 boroughs), Long Island, Rockland, Orange, Putnam, Dutchess, Ulster & Sullivan counties.

** Full-time employment is defined by the number of hours per week an employee has to work to qualify for benefits.

*** Employees who may fall in the ‘other; category include but are not limited to, seasonal and union employees.

This Group Attestation Form is available at or contact the Client Services Department at 888.313.7277 option 1.

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Group Attestation Form - Healthpass