Verification Of Employment Form - New York State Department Of Health printable pdf download

Verification Of Employment Form - New York State Department Of Health

Attachment IV

NEW YORK STATE DEPARTMENT OF HEALTH

Verification of Employment

Office of Health Insurance Programs

Name

___________________________________________________ App Reg./Case # : _______________________

Social Security Number: _______________________

Address: _________________________________________________________________________________________

City: _______________________________________ State: _______________________ Zip Code: _______________

For Office Use Only

To be completed by the employer:

I certify that _________________________ works for me as ______________________________________.

(What do you do?)

This employee is paid each (circle one):

Week

Two weeks

Twice per month

Does the employee have access to New York State Health Insurance?

Yes

Does the employee have dependents enrolled in his/her employer sponsored coverage?

Yes

Please supply the following information:

Last consecutive weeks

Date paid

Gross pay – Include tips, commissions and

bonuses

If no longer employed, date last worked: ___________________________________________

Business name: ______________________________________________________________________________________

Business address: ____________________________________________________________________________________

City: ___________________________________________

State: ____________________________________________

Zip: __________________________________ Business telephone: ___________________________________________

Employer’s name (please print): _________________________________ Title: _________________________________

Employer’s signature: _________________________________________ Date: _________________________________

DOH-XXXX (0X/10)

Verification Of Employment Form - New York State Department Of Health