New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 21 - SMALL EMPLOYER HEALTH BENEFITS PROGRAM
Subchapter 6 - STANDARD EMPLOYER AND EMPLOYEE APPLICATION AND SMALL EMPLOYER CERTIFICATION FORMS
Section 11:21-6.1 - Standard application form

Universal Citation: NJ Admin Code 11:21-6.1

Current through Register Vol. 56, No. 18, September 16, 2024

(a) All small employer carriers offering small employer health benefits plans with an effective date on or after January 1, 1994, shall use the standard application form approved by the Board and available on the Board's website at www.state.nj.us/dobi/division_insurance/ihcseh/sehforms.html.

(b) Small employer carriers shall require any small employer applying for a small employer health benefits plan to be issued by that small employer carrier to complete, as part of the application, the New Jersey Small Employer Certification form approved by the Board and available on the Board's website at www.state.nj.us/dobi/division_insurance/ihcseh/sehforms.html.

(c) The application requires the following types of information:

1. The policyholder name and contact information;

2. The Federal Tax ID Number;

3. The type of business and nature of the business;

4. The number of employees, classes of employees, and coverage type;

5. The status with respect to COBRA and Medicare as secondary payor;

6. The waiting period;

7. The contribution percentage;

8. Affiliates;

9. Benefit options;

10. Replacement information;

11. Continued coverage;

12. Agent/producer information; and

13. A signature section.

(d) The New Jersey Small Employer Certification requires the following information:

1. The status as small employer;

2. Work locations;

3. The participation calculation;

4. The application of Federal laws; and

5. The certification signature.

Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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