DHAS-39, Health Insurance Information
|New Jersey Department of Health |FOR STATE USE ONLY |
|Health Insurance Continuation Program | |
|PO Box 363 | |
|Trenton, NJ 08625-0363 | |
|HEALTH INSURANCE INFORMATION | |
| |Record # |
| |FEIN # |
| | W9 VCH |
| |Vendor Maintenance |
| |
|Name |Social Security Number |
| | |
|Street Address |Telephone Number |
| | |
|City, State, Zip Code |
| |
|BEFORE WE CAN BEGIN MAKING YOUR INSURANCE PAYMENTS, WE MUST HAVE YOUR ORIGINAL PREMIUM NOTICE(S) FROM YOUR INSURANCE COMPANY, |
|EMPLOYER/FORMER EMPLOYER/UNION THAT INCLUDES INFORMATION ON PREMIUM AMOUNTS, WHEN PAYMENTS ARE DUE, AND WHERE PAYMENTS SHOULD BE SENT. |
|I hereby authorize having future premium notices sent to the HICP, PO Box 363, Trenton, NJ 08625-0363. |
|Signature: _____________________________________________________ Date: ______________________ |
|1. Type of Insurance Coverage; Individual Group COBRA |
| COBRA Start | |/ | |/ | | |COBRA End: | |/ | |/ | | |
| COBRA Extended: Yes No |
| Group Name if Under COBRA: | | |
| A Co-Pay - Amount: | | |
| B Deductible - Amount: | | |
|2. Insurance Policy through: Current Employer Former Employer Union Self |
|3. Employer or Union Providing Insurance Coverage |
| Name: | | |
| Address: | | |
| City, State, Zip: | | |
| County: | | |
| Contact Person: | | |Telephone No.: | | |
|4. Names of Other Individuals Covered by This Policy Besides Yourself: |
| | | | | |
| | | | | |
| Family Coverage: Family Single Parent/Child |
|5. Name of Health Insurance Company: | | |
| Address: | | |
| City, State, Zip: | | |
| County: | | |Policy Number: | | |
| Telephone No.: | | | |Group Number (If Applicable): | | |
|6. Premium Payments |
| Amount of Premium Payment: |$ | |
| Monthly Quarterly Other: | | |
| Date Next Premium Payment Due: | |/ | |/ | | |
| Premium Payments Should be Made Payable to: | | |
| Premium Payments Should be Sent to: |
| Name of Company: | | |
| Address: | | |
| City, State, Zip: | | |
| |
|DHAS-39 |IT IS THE APPLICANT'S RESPONSIBILITY TO NOTIFY THE HEALTH INSURANCE CONTINUATION PROGRAM (HICP) OF ANY CHANGE IN INSURANCE PREMIUM, POLICY |
|MAR 14 |TYPE, RESIDENCE ADDRESS, OR TELEPHONE NUMBER. ALSO, APPLICANT MUST SEND TO THE HICP THE ORIGINAL OF ALL PREMIUM NOTICES (BILLS) RECEIVED. |
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