Sole Proprietor And Group Of One Attestation Form

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Sole Proprietor and Group of One
Attestation Form
I.
Business Organization Information:
a. Name of Organization:
__________________
Tax ID # or SS #:
_______________________________
Primary Business Activity: _________________________________________
Address:
__________________
__________________
City:
State:
Zip:
b. Contact Information for Business Organization
Name:
Fax:
Title:
Phone Number:
II.
Sole Proprietor Attestation:
By executing this document, I hereby attest that: (i) the above described business organization is not an
association, group purchasing organization or employee leasing organization and was formed for a lawful
business purpose and not for the primary purpose of obtaining group insurance; (ii) I am the owner and operator
of the above described business organization; (iii) I work a minimum of twenty (20) hours per week for this
business organization; I derive the majority of my earned income (non-passive or non-investment) from the
income generated from the above business organization; (iv) I seek health coverage only for myself and my
eligible dependents through the above described business; (v) I (and my eligible dependents) am the only person
eligible for health coverage through the above described business organization; (vi) I will promptly advise
Oxford in the event that any of the statements made in this Attestation are no longer accurate.
III.
S-Corporations with “One Eligible Employee” Attestation:
By executing this document, I hereby attest that: (i) the above described business organization is not an
association, group purchasing organization or employee leasing organization and was formed for a lawful
purpose and not for the primary purpose of obtaining group insurance; (ii) I am the sole shareholder of the above
described business organization; (iii) I am currently employed by the above described business organization and
work a minimum of twenty (20) hours per week for the business organization; (iv) I derive the majority of my
earned income (non-passive or non-investment) from services provided to the above business organization; (v) I
seek health coverage only for myself and my eligible dependents as listed on my enrollment form; (vi) I (and my
eligible dependents) am the only person eligible for health coverage through the above described business
organization; and (vi) I will promptly advise Oxford in the event that any of the statements made in this
Attestation form are no longer accurate.
IV.
Tax Forms and other Documents (applicable to both Sole Proprietors and S-Corporations):
By executing below, I agree to provide upon request appropriate tax forms to Oxford to validate the eligibility
status. Before application will be considered, the applicant must execute this Attestation Form and provide the
tax information and related documents indicated on the attached correspondence. Oxford reserves the right to
modify these documentation and eligibility requirements in the future.
NY-07-134
9503

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