Dependent Information Information& Insurance Verification Form - North America Administrators, L.p.
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1NORTH AMERICA ADMINISTRATORS, L.P.
NORTH AMERICA ADMINISTRATORS, L.P.
NORTH AMERICA ADMINISTRATORS, L.P.
NORTH AMERICA ADMINISTRATORS, L.P. - - - - DEPENDENT
DEPENDENT
DEPENDENT
DEPENDENT INFORMATION
INFORMATION
INFORMATION
INFORMATION & INSURANCE VERIFICATION
& INSURANCE VERIFICATION
& INSURANCE VERIFICATION
& INSURANCE VERIFICATION FORM
FORM
FORM
FORM
This form is to be completed by the Employee. Please complete
This form is to be completed by the Employee. Please
complete
Return to: NAA - Eligibility Dept.
This form is to be completed by the Employee. Please
This form is to be completed by the Employee. Please
complete
complete
only the S S S S ection
only the
ection that applies.
that applies. Please complete a separate form
Please complete a separate form
P O Box 1984
only the
only the
ection
ection
that applies.
that applies.
Please complete a separate form
Please complete a separate form
for each Dependent.
for each D
ependent.
Nashville, TN 37202
for each D
for each D
ependent.
ependent.
Phone: 615-256-3561; Toll Free: 800-411-3650
Fax:
615-255-6654
Use a se
Use a separate sheet or the back of this form, if necessary
Use a se
Use a se
parate sheet or the back of this form, if necessary
parate sheet or the back of this form, if necessary
parate sheet or the back of this form, if necessary. . . .
EMPLOYER: _________________________________Employee: ________________________SSN:____________________________
Dependent Name: ____________________________ Date of Birth: _____________________SSN: ____________________________
Sex: ________
Relationship to Employee: (CHECK ONE)
(CHECK ONE) [ ] Natural or
[ ] Natural or Ado
Adopted Child
pted Child [ ] Step
[ ] Step- - - - Child
Child [ ]
[ ] Other
Other_______
________________
__________ _ _ _ ________
________
(CHECK ONE)
(CHECK ONE)
[ ] Natural or
[ ] Natural or
Ado
Ado
pted Child
pted Child
[ ] Step
[ ] Step
Child
Child
[ ]
[ ]
Other
Other
_______
_______
_________
_________
________
________
1. 1. 1. 1.
If Natural Child or Adopted Child:
If Natural Child or Adopted Child:
If Natural Child or Adopted Child:
If Natural Child or Adopted Child:
Did this child have any other medical coverage in the past 18 months?
[ ] YES
[ ] NO
If YES and child is over age 19
and child is over age 19, provide a copy of the Certificate of Creditable Coverage.
and child is over age 19
and child is over age 19
Is the child employed full-time?
[ ] YES
[ ] NO
If YES, does this child have any other medical coverage currently in force?
[ ] YES
[ ] NO
If YES, provide the following information for the other insurance carrier or plan and provide a copy of that insurance card:
Name/Address___________________________________________________________________________
Policy/Group No._____________________ Telephone No. ________________________________________
Is there a document of any kind that requires you or any other person to maintain health coverage for this child?
[ ] YES
[ ] NO
If YES, a copy of the document
If YES, a copy of the document MUST be returned with this form.
If YES, a copy of the document
If YES, a copy of the document
MUST be returned with this form.
MUST be returned with this form.
MUST be returned with this form.
2. 2. 2. 2.
If Step
If Step
If Step
If Step- - - - Child:
Child:
Child:
Child:
Please provide a copy of spouse’s Divorce Decree or QMCSO.
Did this child have any other medical coverage in the past 18 months?
[ ] YES
[ ] NO
If YES and child is over age 19
and child is over age 19, provide a copy of the Certificate of Creditable Coverage.
and child is over age 19
and child is over age 19
Is the child employed full-time?
[ ] YES
[ ] NO
Does this child have any other medical coverage currently in force?
[ ] YES
[ ] NO
If YES, provide the following information for the other insurance carrier or plan and provide a copy of that insurance card:
Name/Address_________________________________________________________________________
Policy/Group No.__________________ Telephone No. ________________________________________
3. 3. 3. 3.
If Other:
If Other:
If Other:
If Other:
Did this individual have any other medical coverage in the past 18 months?
[ ] YES
[ ] NO
If YES and
and the individual
the individual is over age 19
is over age 19, provide a copy of the Certificate of Creditable Coverage.
and
and
the individual
the individual
is over age 19
is over age 19
Is this individual employed full-time?
[ ] YES
[ ] NO
Does this individual have any other medical coverage currently in force?
[ ] YES
[ ] NO
If YES, provide the following information for the other insurance carrier or plan and provide a copy of that insurance card:
Name/Address_________________________________________________________________________
Policy/Group No.__________________ Telephone No. ________________________________________
I hereby certify that the above statements are true and complete to the best of my knowledge and I realize that
I hereby certify that the above statements are true and complete to the best of my knowledge and I realize that
I hereby certify that the above statements are true and complete to the best of my knowledge and I realize that
I hereby certify that the above statements are true and complete to the best of my knowledge and I realize that
failure to provide accurate information may cause a loss of benefits.
failure to provide accurate information may cause a loss of benefits.
failure to provide accurate information may cause a loss of benefits.
failure to provide accurate information may cause a loss of benefits.
______
____________________________________________________
______
______
______________________________________________
______________________________________________
______________________________________________
___________
___________
___________
_____________________________
__________________
__________________
__________________
Employee Signature
Employee Signature
Employee Signature
Employee Signature
Date
Date
Date
Date
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