Small Group Underwriting 1099 Contractor Verification Form printable pdf download

Small Group Underwriting

1099 Contractor Verification Form

Date: _______________________________________________________________________________

Employer Name: ______________________________________________________________________

Contractor Name: _____________________________________________________________________

To the Employer:

We have received your request to enroll the above named individual for coverage under your group insurance

plan. This person is compensated by method of a 1099-Miscellaneous Tax Form, used for reporting

compensation to a non-employee.

To enable Sharp Health Plan to establish eligibility for this individual as a legitimate, full-time employee of

your company and thereby entitled to coverage, please complete the following and return by fax at (619) 228-

2446.

1. Do you control the working hours, hiring, training, and

Yes

discharging of this individual?

2. How many hours a week does this individual work for you?

______ Hours/Week

3. How many weeks per year does this individual work for you?

______ Weeks/Year

4. Do you agree to contribute the same amount of money toward

Yes

the premium as the regularly taxed employees?

5. Is there a contract between this individual and yourself?

Yes

If so, please provide a copy.

6. Does this individual appear on the prior carrier billing statement?

Yes

7. Do you agree to offer similar coverage for all future 1099

Yes

employees?

8. Are more than 25% of the enrolled employees 1099 employees?

Yes

Copies of this individual’s last years 1099-Misc Tax Form and tax returns are attached.

Both parties have read the statement below and acknowledged by signing and dating.

I understand that misstatements or false information may result in insurance coverage being denied to the above named individual

as of the effective date of the plan, with no benefits payable. I authorize Sharp Health Plan to review payroll employment records

(e.g., front page of a 1040 Tax Return, IRS Form SS-8) and interview individuals at any time while covered under the above

group plan to verify the accuracy of the information contained herein.

Employer’s Signature:

Date:

Contractor’s Signature:

Date:

Small Group Underwriting 1099 Contractor Verification Form