Self-Employment Verification Form
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2TEXAS HEALTH INSURANCE POOL
SELF-EMPLOYMENT VERIFICATION FORM
Individual’s Information (SECTION A)
Applicant/Member Name:
Applicant/Member Social Security Number or Unique ID
Spouse’s Name (if any):
Employment Information for:
Self
Spouse
Mother
Father
Other __________________
Business Information (SECTION B)
Employer/Business Name:
Telephone Number:
Address:
How long have you been self-employed?
How many hours a week do you usually work?
Yes No
Do you have any full time employees (work 30 hours per week or more)?
If so, how many?
Yes
No
Do you provide group health benefit coverage, either insured or self-insured?
If insured, the name of the insurance company: __________________________________________________________
Yes
No
Do you pay all or part of the cost of employee coverage for any employees other than yourself?
If yes, please explain:
If you pay all or part of the cost for employee coverage, is the amount paid for insurance
Yes
No
included in the employees’ taxable wages?
Yes
No
If yes, can the employee use the amount paid for any other purpose?
If yes, please indicate other permissible uses:
Does the employer pay for or reimburse or intend to pay or reimburse the person, named above as the employee, for all or part
of the Pool premium, either directly or indirectly, including through a Health Reimbursement Arrangement (HRA) or Section
Yes No
125 Plan (Cafeteria Plan)?
Yes
No
Do you intend to provide health coverage for employees in the next 6 months?
Yes
No
Are you working with an agent or third party administrator to secure or establish group coverage?
If yes, the name and telephone number of the agent or the TPA:
I understand that Texas Insurance Code statutes, §1501.352 and §1506.159 prohibit an agent, a third party
administrator or insurer from attempting to arrange or assist in excluding an eligible individual from an employer
health benefit plan, specifically by attempting to arrange or assist in obtaining coverage from the Texas Health
Insurance Pool. I hereby certify that the above answers are true and correct. I further understand that a false or
fraudulent statement or representation, made in order to procure coverage under a health benefit plan, including a
public plan such as the Texas Health Insurance Pool, for a person who is ineligible for such plan, is a violation of the
anti-fraud provisions of the Health Insurance Portability and Accountability Act, 18 USC §1035, to which civil and
criminal penalties, including imprisonment, can apply.
Employer’s Signature: ________________________
Title: ______________________________
Date: ____________
Printed Name: ______________________
Another copy of this form is provided on the other side.
SEVF 10/2011
Both sides are only required if more than one person is self-employed.
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