N.J. Admin. Code § 11:21-6.1 - Standard application form

Current through Register Vol. 54, No. 7, April 4, 2022

(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.

Notes

N.J. Admin. Code § 11:21-6.1
Amended by 48 N.J.R. 2360(a), effective 11/7/2016

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