Hint Group Enrollment - Group Enrollment/change Request Form Page 5
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71. Employer Name:________________________________________________________________________________
[F.] Additional Spouse/Civil Union
Partner/Domestic Partner Information – to be
Employer Address:______________________________________________________________________________
completed by [Employee] If not applicable, please
City, State, Zip Code:____________________________________________________________________________
mark as “NA.”
Employer Phone: (
)
2a.
2b. Please explain why the address is different:
Street/Apt:______________________________________________________________________________________
_____________________________________________
Street/Apt:______________________________________________________________________________________
_____________________________________________
City, State, Zip Code:__________________________________________________________________________
[G.] Additional Child Information – to be completed by [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):________________________________________________________________
Name(s):_______________________________________________________________
Street/Apt:_______________________________________________________________
Street/Apt:_____________________________________________________________
Street/Apt:_______________________________________________________________
Street/Apt:_____________________________________________________________
City, State, Zip Code: _____________________________________________________
City, State, Zip Code:_____________________________________________________
Reason:_________________________________________________________________
Reason:________________________________________________________________
[H.] Additional Information for Dependent Under 30
This Continuation Election is being made:
Continuation Elections – Provide information below
During an Open Enrollment period [for the group] [for the Over-Age Child based on his/her age-out anniversary]
about children listed in Section D for whom a Dependent
Within 30 days prior to the attainment of the limiting age (when the Dependent will become an Over-Age Child)
Under 30 continuation election is being made.
Within 30 days after the Over-Age Child has established eligibility for a Chapter 375 Continuation Election
[
Special May 12, 2006 through May 11, 2007 enrollment period]
[I.] Race/Ethnicity – to be completed by the [Employee], at
Choose a category that most closely describes you:
his/her option. NOTE: your response is appreciated but NOT
American Indian or Alaskan Native
Black, not of Hispanic origin
Hispanic
required!
Asian or Pacific Islander
White, not of Hispanic origin
[J.] [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: ________________________________
[K.] Over-Age Child’s
I represent that all the information supplied in this application regarding the [Dependent Under 30] Continuation Election is true and complete. I
Signature
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 30 Continuation Election.]
Signature: _________________________________________________________________________ Date: ________________________________
[L.] [Employer]
The requested activity is believed eligible and is approved by the [Employer]. [In addition, the [Employer] consents to payroll deduction for
Verification
Dependent Under 30 Continuation Election:
Yes
No]
Employer Representative: _____________________________________________________ Date: _______________________________________
Representative’s Title: _________________________________________________________
NJ-HINT-Group
5
[Internal Carrier Form Number]
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