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

E. Additional Spouse/Civil Union Partner/Domestic Partner Information - To be completed by the Employee. If not applicable, please mark as “NA”.

Employer Name: ____________________________________________________________________________________________________________

Employer Address: __________________________________________________________________________________________________________

City, State, Zip Code: _____________________________________________________________ Employer Phone:_____________________________

Please explain why the address is different:

Street/Apt:____________________________________________________________

________________________________________

Street/Apt:____________________________________________________________

2a.

2b.

________________________________________

City, State, Zip Code: ___________________________________________________

_________________________________________

F. Additional Child Information - To be completed by the Employee. Provide information below about children listed in Section D, if they have a different address

from the employee. If multiple children are at an address, you may list them together. Attach additional pages as necessary, signed and dated.

Name(s):__________________________________________________________

Street/Apt:_________________________________________________________

City, State, Zip Code:_________________________________________________

Reason:___________________________________________________________

G. Race/Ethnicity - To be completed by the Employee, at his/her option. NOTE: your response is appreciated but NOT required!

Choose a category that most closely describes you:

American Indian or Alaskan Native

Black, not of Hispanic origin

Hispanic

Asian or Pacific Islander

White, not of Hispanic origin

H. Employee Signature

I represent that all the information supplied in this application is true and complete. I hereby agree to the Conditions of Enrollment set forth in this Enrollment/Change

Request form. I authorize deductions from my earnings for any contributions required from me.

Signature: ___________________________________________________________________________________________ Date: ________/________/___________

I. Over-Age Child’s Signature

I represent that all the information supplied in this application regarding the Dependent Under 31 Continuation Election is true and complete. I hereby agree to the

Conditions of Enrollment set forth in this Enrollment/Change Request form. I hereby agree to make contributions required from me for the Dependent Under 31

Continuation Election.

Signature: ___________________________________________________________________________________________ Date: ________/________/___________

J. Employer Verification

The requested activity is believed eligible and is approved by the Employer. If termination of coverage is requested, the Employer certifies that no employee

contributions have been taken for any period subsequent to the requested termination date.

Employer Representative: ______________________________________________________________________________ Date: ________/________/___________

Representative’s Title: _______________________________________________________________________________

NJ-HINT-Group

OHI NJS MEF 6856 R12