United Healthcare (Oxford) Eligibility Verification Form (Page 2 of 3) in pdf

Employer Information Form

Employer Name (legal) & DBAs:

Customer/Group #:

Federal Tax ID #:

«CustomerNumber»

Nature of Business (products sold / service provided):

E-mail Address:

Telephone #:

Current Administrative Location of Your Business (if multiple

Billing Address:

locations, please list all locations):

Type of Business Organization (check box below):

Sole Prop.

S-Corp.

C-Corp.

LLC

LLP (Partnership)

Farm

Non-Profit

Other ___

Employee Eligibility: All of the Employer’s full-time permanent employees who work at least ______ hours per week are eligible

(must work a minimum of 20 hours per week)

1. Do you file a consolidated tax return as an affiliated group? (circle one) *If yes, please provide the most recent Form 851.

YES

N/A

2. Is your group a Professional Employer Organization (PEO), Employee Leasing Company (ELC), or other such entity that is a co-

employer, with your client(s), of client-site employee(s)?

The PEO relationship involves a contractual allocation and sharing of employer

(circle one)

responsibilities between the PEO and the client. This shared employment relationship is called co-employment.

YES

If you answered yes, then by signing this form, you agree with the certification in this section: I hereby certify that my company is a

PEO, ELC, or other such entity and that only those employees who are the corporate employees of my company, and not my co-

employees, are permitted to enroll in this group policy. I understand that UnitedHealthcare will not cover the co-employees under this

group policy.

We require the most recent copy of your state Quarterly Wage and Tax Report (NYS-45).

If your company does not file a Quarterly Wage and Tax Report (NYS-45) or you have employees or owners who are not listed on the

Quarterly Wage and Tax Report, please submit the following tax documentation where applicable:

 Sole Proprietorship – IRS Schedule C (Form 1040) or Schedule F (farms)

 S-Corporation – IRS Schedule K-1 (Form 1120S)

 C-Corporation – IRS Form 1120 (pages 1-2), including Schedule E & Schedule K #5

 Partnership / LLP – IRS Schedule K-1 (Form 1065)

 LLC – Appropriately filed IRS schedule(s)

 Non-Profit – Most recent quarter federal Form 941 and current two-week payroll

 New Hires – Most recent two-week payroll report

 Other: _______________________________

Next to each employee listed on the Quarterly Wage and Tax Report (NYS-45), please indicate the following:



State of residency



Status code (from the list below)



Date of hire or termination date (if applicable)

The submitted documents must identify all employees, owners, partners and contracted employees of your business, not only

those who have coverage with UnitedHealthcare and/or its affiliates.

Status Codes

A Employee is actively enrolled (plan subscriber).

Employee is covered under spouse’s employer plan.

M Employee is covered under Medicare.

O Employee has other coverage. Specify nature of coverage

(e.g., individual, group, military, parental, etc.)

Employee is terminated (no longer works for this

D Employee is declining coverage (i.e., due to cost or doesn’t

employer).

want). Only use this code if the employee is full-time with no

other coverage or waiver reason.

Employee is part-time and works less than the required

Employee is not actively working due to Leave of Absence or

full-time hours (includes temporary and seasonal

other reason. Please provide the last tax form or payroll the

employees).

employee is listed on.

W Employee is full-time but is in the policy’s waiting period.

C Person is covered under state or federal (COBRA) continuation

Indicate date of hire and date the employee will be eligible

law. Indicate continuation start date and whether coverage is

for coverage.

provided by a prior employer or by your company.

THE UNDERSIGNED EMPLOYER, OR DULY AUTHORIZED REPRESENTATIVE, CERTIFIES THAT THE FOREGOING INFORMATION IS TRUE,

CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE OR BELIEF, AND FULLY UNDERSTANDS THAT ANY FALSE

STATEMENTS OR FAILURE TO PROVIDE ALL AVAILABLE INFORMATION MAY CONSTITUTE THE BASIS FOR TERMINATION OF

COVERAGE AT THE OPTION OF THE INSURER AND/OR THE GROUP POLICY’S ADMINISTRATIVE REPRESENTATIVE.

Name & Title (please print):

Signature:

Date:

NY-10-749

United Healthcare (Oxford) Eligibility Verification Form Page 2

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