Nongroup Enrollment/change Request Form Page 2
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7Are you covered under Other Health Coverage?
Yes
No
Are you eligible but not covered under Other Health Coverage?
Yes
No
If yes:
If yes, what is it?
Payer Name: ____________________________________________________________
Group plan via employment (specify payer): _______________________________
Policy #: ___________________________________________
Medicaid/NJFamilyCare
Medicare ID#, if any:
Medicare
Why are you applying for individual coverage? ________________________________
Other (specify): ___________________________
Previous Coverage?
Yes
No
What was it?
What Plan Type?
Cost-sharing requirements:
If Yes:
Individual
Indemnity
Deductible amount: $______________
Effective date: _____/_____/_____
Termination date: _____/_____/_____
Group
PPO
Coinsurance amount: _________%
Payer Name:____________________________________________________
Medicaid/NJFamilyCare
POS
Copayment amount: $_____________
Policy #:____________________________
Other (specify):
HMO
[Submit a Certificate of Creditable Coverage]
Other
Did coverage terminate as a result of fraud or failure to pay premiums?
Yes
No
Were you allowed to make a COBRA continuation election, or a continuation election under State law, if any, when coverage ended?
Yes
No
If Yes, did you elect to continue and remain covered for the entire continuation period available to you?
Yes
No
Were you covered for 18 months or more under any previous plan(s)?
Yes
No
Have you experienced more than a 63-day break in coverage between any previous plan, including your most recent plan and the date of this application?
Yes
No
C. Plan Option – Check one [Plan Name] [and] [Copay] [and] [or] [Deductible] [and] [or] [Coverage Status]
D. Other Individuals Covered – Identify individuals other than yourself for whom you are adding/changing/removing coverage. Attach additional pages if necessary, dated and
signed by you.. [Attach proof if full-time post-secondary student.] [Attach proof of disability.]
1. Spouse/Domestic Partner/Civil
2. Child
3. Child
4. Child
Union Partner
Add
Remove
Other
Add
Remove
Other
Add
Remove
Other
Add
Remove
Other
Name (last, first, MI)
Name (last, first, MI)
Name (last, first, MI)
Name (last, first, MI)
L:________________________________
L:_________________________________
L:_________________________________
L:_______________________________
F:________________________________
F:_________________________________
F:_________________________________
F:_______________________________
MI:
MI:
MI:
__
MI:
Birthdate (mm/dd/yyyy):
Birthdate (mm/dd/yyyy):
Birthdate (mm/dd/yyyy):
Birthdate (mm/dd/yyyy):
Male
Female
Male
Female
Male
Female
Male
Female
Social Security Number:
Social Security Number:
Social Security Number:
Social Security Number:
NJ-HINT-Individual
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[Internal Carrier Form Number]
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