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

INSTRUCTIONS

Employers – You must complete the Employer Group Information and sections

QUALIFYING EVENTS

A and J in order for this application to be processed.

COBRA and NJSGC

C1. Termination of job or reduction in hours

Employees – You must complete sections B through H and submit the signature

C2. Employee enrollment in Medicare (COBRA only)

of each Over-Age Child for which a Dependent Under 31 Continuation Election is

C3. Divorce (COBRA/NJSGC); civil union dissolution (NJSGC)

made in accordance with Section I in order for this application to be processed.

C4. Death of employee

C5. Loss of dependent child status under the plan

Please PRINT except when a signature is requested.

•

C6. Disability (occurring subsequent to another qualifying event)

If a dependent is disabled and you want to continue his or her coverage

•

beyond age 26, you do not have to make a COBRA/NJSGC or Dependent

Dependent Under 31

Under 31 election. Instead, select “Other” in Section A3, and attach proof of

D1. Loss of dependent status and otherwise eligible

disability.

D2. Reestablish eligibility: residency

For provider addresses, include the zip code plus the four digit extension

•

D3. Reestablish eligibility: nonresident full-time student

(11 digits)

D4. Reestablish eligibility: change in marital status

You can obtain the providers’ correct names and addresses from the

•

D5. Reestablish eligibility: change in parental status

appropriate provider directory.

D6. Reestablish eligibility: termination of other coverage

CONDITIONS OF ENROLLMENT – APPLICANT ACKNOWLEDGEMENTS AND AGREEMENTS

On behalf of myself and the dependents listed in this Enrollment/Change Request form, I acknowledge that:

1. I authorize any physician or medical professional, hospital, clinic or other medical care institution, carrier, consumer reporting agency, and any

employer to give Oxford Health Insurance, Inc., or any consumer reporting agency acting on behalf of Oxford Health Insurance, Inc., information

pertaining to employment, other health coverage, and medical advice, treatment or supplies for any physical or mental condition relevant to me

or a minor dependent applying for coverage. I agree that this authorization shall be valid for 30 months from the date I sign this

Enrollment/Change Request form, unless revoked at an earlier date.

2. I agree that, if I revoke this authorization before it expires, such revocation shall not affect any action that Oxford Health Insurance, Inc. has

taken in reliance on the authorization.

3. I understand I may receive a copy of this authorization if I request one.

4. I agree Oxford Health Insurance, Inc. will provide coverage in accordance with the terms of the contract for the group policy.

5. I agree that the provision of coverage and benefits is contingent upon payment of premiums and may be terminated in accordance with the

terms of the group policy if premiums are not paid timely. I authorize my Employer to withhold payments from my wages as contribution to the

premium, as appropriate.

UHCNJ578529-004 10/14

NJ-HINT-Group

OHI NJS MEF 6856 R12

New Jersey Small Employer - Member Enrollment/change Request Form - Ohi - 2014 Page 4

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