New Jersey Small Employer - Member Enrollment/change Request Form - Ohi - 2014

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New Jersey Small Employer – Member Enrollment/Change Request Form – OHI
Group Information – To be completed by Employer:
Group Name:
Group Number:
Contract Specific
Package:
Oxford Health Insurance, Inc.
Mailing Address: P.O. Box 29142, Hot Springs, AR 71903
1-800-444-6222
A. Type of Activity – To be completed by Employer. Refer to instructions on page 4 before completing this form. Print clearly.
Effective Date/
Activity – Check all that apply
Date of Hire/Reason for Change
Date of Event
Enrollment of a new Subscriber
_____/_____/_____
Date of Hire: _____/_____/_____
Add Spouse
_____/_____/_____
_______________________________________________
Add Civil Union Partner
_____/_____/_____
_______________________________________________
Add Domestic Partner
_____/_____/_____
_______________________________________________
Add Dependent Child
_____/_____/_____
_______________________________________________
Add Over-Age Child as a Dependent Under 31 (and complete section A 4)
_____/_____/_____
_______________________________________________
Employee Withdrawal/Termination
_____/_____/_____
_______________________________________________
Remove Spouse
_____/_____/_____
_______________________________________________
Remove Civil Union Partner
_____/_____/_____
_______________________________________________
Remove Domestic Partner
_____/_____/_____
_______________________________________________
Remove Dependent Child
_____/_____/_____
_______________________________________________
Remove Over-Age Child as a Dependent Under 31
_____/_____/_____
_______________________________________________
Name Change
_____/_____/_____
_______________________________________________
Change Plan
_____/_____/_____
_______________________________________________
Other
_____/_____/_____
_______________________________________________
Add/Change Office ID Numbers: Primary/OB/Gyn
_____/_____/_____
_______________________________________________
For Employee
For Dependent or Over-age Child
For Spouse/Civil Union Partner*/Domestic
Total Disability*
COBRA/NJSGC
Partner
COBRA/NJSGC
Length of Continuation (in months):
Length of Continuation (in months):
Length of Continuation (in months):
18
36
18
36
18
29
Date of Loss of Coverage: ___/___/___
Loss of Coverage: _____/_____/_____
Date of Loss of Coverage:_____/_____/_____
Qualifying Event:_________________**
Qualifying Event #:__________________**
Date of Qualifying Event: ___/___/___
Qualifying Event #:_______________**
Date: _____/_____/_____
Date of Qualifying Event: _____/_____/_____
Dependent Under 31
*Civil union partners are eligible to make an election
pursuant to NJSGC, if applicable.
Qualifying Event #:__________________**
*Attach proof of disability.
**Qualifying event #s: see list in Instructions
B. Employee Information – To be completed by the Employee
Name (Last, First, MI):
SSN:
Birthdate (mm/dd/yyyy):
Male
Female
Street/Apt:______________________________________________________________________________________________________________________
Street/Apt:______________________________________________________________________________________________________________________
City:__________________________________________________________________ State:________________________ Zip Code: ___________________
Preferred Phone:
Home
Cell
Work ___________________________ Alternate Phone:
Home
Cell
Work __________________________
Email:__________________________________________________________________________________________________________________________
Employment Date:
Employer Name: _________________________________________________________________________________
Address:________________________________________________________________________________________
_______/_______/_______
City:_______________________________________________ State:______________ Zip Code: _________________
Hours worked per week: _______
Phone: ______________________________ Email: _____________________________________________________
NJ-HINT-Group
OHI NJS MEF 6856 R12
1

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