New Jersey S mall Group
(1 -50 Em p lo y e e s)
Effective January 1 , 2016
The following underwriting guidelines must be met for Health Republic Insurance of New Jersey (HRINJ) to accept a
group application:
1.
The 1st and the 15th effective dates of coverage may be selected as long as all information is received by HRINJ
five (5) business days on or before the requested effective date i. If the initial effective date is on the first of the
month, the group will renew on the first of that same month every year.
2.
The Employer must contribute at least 10% toward the total group premium (unless purchased during an open
enrollment period).
3.
Class carve outs are allowed as long as the employer is not sponsoring another plan for the excluded
employees/classes. Minimum participation requirements apply.
4.
Participation: New Jersey Small Group (1-50) requires that 75% of eligible employees after valid waivers be
enrolled in an HRINJ product. Valid waivers are a Group Health Plan offered by spouse, parent, or another
employer, Medicare, Medicaid, NJ Family Care, TRICARE or other Federal or State sponsored Health Plan.
5.
HRINJ will reduce the participation requirement to 50% of the eligible employees IF:
A small employer maintains the same or greater contribution toward employee coverage for the new plan year as was
provided during the current plan year.
AND One or more of the employees who were covered under the small employer’s health benefit plan during the current
year refuse coverage for the new plan year AND that employee (s) state the reason coverage is being refused is they are
securing or secured individual coverage with an APTC (Accelerated Premium Tax Credit) under federal law and they
provide evidence of eligibility for such individual coverage and APTC.
AND the small employer fails the 75% participation requirement solely because employees have refused coverage.
6.
In establishing the percentage of employee participation, a one-to-one credit shall be given to each employee
covered by a Group Health Plan offered by spouse, parent or another employer, Medicare, Medicaid, NJ Family
Care, TRICARE or other Federal or State sponsored Health Plan.
For example: A small group has five eligible employees and three of those employees each have valid
waivers as listed above in #7, these three employees are to be included in the count for the number of
enrolling employees when determining the participation percentage. In this way, a group is not
penalized if they have employees covered by a Group Health Plan offered by spouse, parent, or another
employer, Medicare, Medicaid, NJ Family Care, TRICARE or other Federal or State sponsored Health
Plan.
SGUG (2015/01)
HRINJ © 2015
1
7. Document Submission Requirement checklist:
o
o
o
o
o
First month's Premium Check (1/2 month’s premium for 15th of the month effective date)
Group Application
New Jersey Employer Certification
Completed and signed waiver form, if applicable
Signed copy of the proposal. Please note: Final rates are based on final enrollment by plan design
Proof of Business: (groups of 1-5 employees)
o Schedule C or Schedule K-1 (Owners)
o IRS Form 1120 (Corporate Income)
o Business license
Newly formed businesses only: Articles of Incorporation, Certificate of Formation, Certificate of Incorporation
(signed and completed with a stamp or receipt with issuing date) or Partnership agreement (stamped by state or
notarized)
Proof of Employment:
o
o
o
o
New Jersey WR-30 – Employer Report of Wages Paid for all employees (only required for groups with less
than 6 eligible, full-time employees)
W-4 (for new hires only)
Payroll documents showing withholdings
Schedule C or Schedule K-1 (for owners only)
*Send to: Health Republic Insurance of New Jersey
570 Broad Street
Suite 1100
Newark, NJ 07102
Fax: 201.308.8605
Attn.: Michele Harris
*Or scan and send using secure email only. Instructions for using secure email are located online at
https://newjersey.healthrepublic.us/producer/.
i
This timeframe may be extended in the case of business interruption beyond the control of HRINJ.
SGUG (2015/01)
HRINJ © 2015
2
Health Republic Insurance of New Jersey
570 Broad Street, Suite 1100
Newark, NJ 07102
APPLICATION FOR A SMALL GROUP HEALTH BENEFITS POLICY
Please print or type
Policy number: _____________________________
(Health Republic Insurance of New Jersey Use Only)
□ New Policy □ Change in Policy
Requested Effective Date _______________
Note: The Effective Date will be on or after the date Health Republic Insurance of New Jersey
(HRINJ) approves the application.
SECTION I: POLICYHOLDER INFORMATION
1. Policyholder (full legal name of company):___________________________
2. Tax Identification Number:_______________________________________
3. Main Address:__________________________________________________
Street
City
State
Zip
Mailing Address:________________________________________________
Street
City
State
Zip
Telephone: (
)_______________
Facsimile: (
)_______________
E-Mail address _________________________________
Contract information should be provided  electronically or  hard copy. Check one.
Correspondent:_______________________________________________
4. Type of organization: □ Corporation □ Partnership □ Proprietorship
□ Other (explain):_______________________________
5. Nature of business (specify):________________________________________
SIC Code _________________________
6. Number of eligible employees in your company: ________________________
Refer to the New Jersey Small Employer Certification for the definition of an eligible
employee
7. Number of eligible employees to be insured: __________________________
8. Class or classes to be excluded: _____________________________________
00174 1115
570 Broad Street, Suite 1100, Newark, NJ 07102 | Tel: 888 990 5706 | newjersey.healthrepublic.us
Coverage underwritten by Freelancers Consumer Operated and Oriented Program of New Jersey, Inc. d/b/a
Health Republic Insurance of New Jersey
9. Insurance Requested For: □ Employees Only
□ Employees & Dependents including Spouse
□ Employees & Dependents excluding Spouse
Should the plan provide coverage for domestic partners as permitted by P.L. 2003, c. 246?
□ Yes
□ No
If yes, should the plan provide coverage for coverage of children of a covered domestic
partner? □ Yes
□ No
10. Is the employer subject to the requirements of COBRA?
□ Yes
□ No
11. Is the employer subject to the requirements of Medicare as Secondary Payor Rules for
eligibility due to age?
□ Yes □ No
due to disability? □ Yes □ No
12. Orientation Period: □ Yes
□ No
13. Waiting period before employees become insured: (may not exceed 90 days )
□ Present employees:_________ □ New or Rehired Employees:________
14. Period for Annual Employee Open Enrollment Period: ___________________
15. What percentage of the premium will the employer pay? _______________
16. Deposit $______________
Premium Paid: □ Monthly □ Quarterly □ Automatic checking withdrawal
Premium will be due as of the effective date. The premium for the first month of coverage
must be attached.
Affiliates, subsidiaries or branches (Must be included for purposes of participation)
Legal Name & Location
Number of eligible
employees in this
company
Number of eligible employees to be
insured
SECTION II: SPECIFICATIONS FOR COVERAGE


Full Access Prime
□ Bronze
□Silver
□ Gold
Full Access Core
□ Silver
□ Gold
□ Platinum
2




Full Access Solid
□ Bronze
□ Silver
□ Gold
Full Access Pure
□ Bronze
□ Silver
□ Gold
Active Access Spotlight
□ Bronze
□ Silver
□ Platinum
□Platinum
CentraState Community Plan
□ Bronze
Stand Alone Pediatric Dental (SAPD): Federal law requires coverage for pediatric dental
benefits. Because the Health Republic Medical Plan Options do not contain pediatric
dental benefits, you must buy pediatric dental benefits separately and must provide
assurance that you have, or will obtain a Marketplace-certified SAPD plan.
□ I have purchased or am purchasing a Marketplace-certified SAPD plan with another carrier to
be effective when the medical coverage is effective. I agree to provide information demonstrating
this coverage immediately to HRINJ if requested, that may include the evidence of coverage, the
name of the issuer and applicable policy number. I attest that this information is accurate.
SECTION III: ALL QUESTIONS MUST BE ANSWERED
1. Is there any Group Health Plan:
 now in force and to be continued?
□ Yes
□ No
 currently being applied for?
□ Yes
□ No
If “Yes” identify the name of the Group Health Plan, give a description of the plan(s) and
name of insurance carrier(s)
___________________________________________________________
2. Name of present or prior group carrier_______________________________
Effective date of prior coverage:__________________________________
Cancellation/termination date:_____________________________________
Is the coverage applied for in this application replacing other group insurance?
□ Yes
□ No
If “Yes” give reason_____________________________________________
Plan being replaced: _____________
3.
Are extended benefits provided in case of termination of health benefits?
□ Yes
□ No
4.
To the best of your knowledge are there any current or former employees or their eligible
dependents whose health insurance is being continued?
□ Yes
□ No
3
Please provide the following information for each current/former employee or dependent
on health continuations.
Type of
Continuation
Name of
Continuation
Reason for
Dates
Employee/
State/Federal/
Termination
Dependent
Date of Birth
Extended
Disability
Benefits
/Other
Start
End
If additional space is needed, attach a separate sheet, signed and dated.
5. To the best of your knowledge:
a) Are any employees or dependents presently incapacitated?
□ Yes □No
b) Are any dependent children incapable of self-support due to a physical or mental
disability?
□ Yes □ No
Additional space to explain if Items 1, 2 or 3 were answered “Yes”. Refer to the question number,
and give details including names, where appropriate.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
6. Does the employer participate in an arrangement with a Professional Employer Organization?
□ Yes □ No
(Refer to Advisory Bulletin 00-SEH-02 if you need information concerning what constitutes a
Professional Employer Organizations.)
SECTION IV: AGENT/PRODUCER INFORMATION
Agent/Broker Name: ____________________________________________________________
4
SECTION V: SIGNATURE
It is understood that, except as provided under applicable regulations, no individual shall become
insured while not actively at work on a full-time basis, and only full-time employees are eligible.
(Refer to the definition on the New Jersey Employer Certification.)
It is further understood that no agent has power on behalf of Health Republic Insurance of New
Jersey (HRINJ) to make or modify any request or application for insurance or to bind Health
Republic Insurance of New Jersey (HRINJ) by making any promise or representation or by giving
or receiving any information.
It is further understood that no insurance will be effective unless and until the application is
accepted in writing by Health Republic Insurance of New Jersey (HRINJ). Final rates will be
based on enrollment data as of the policy effective date. No contract of insurance is to be implied
in any way on the basis of the completion and/or submission of this application.
Any person who includes any false or misleading information on an application for an insurance
policy is subject to criminal and civil penalties.
Dated at _______________________ on ____________________
___________________________________ __________________________________
Print name of Officer, Partner or Proprietor Signature of Officer, Partner or Proprietor
_______________________________________________________
Witness to Signature
Note: If there are any modifications to the statements and answers given in this application (i.e.,
crossed out, whited-out, erased information), the applicant must attest to the modifications by
giving a complete signature in the margin near the modification.
5
SGWC 1 (2015/01)
HRINJ © 2015
NEW JERSEY EMPLOYER CERTIFICATION
Legal Name and Address of Employer
Group Policy Number or Group
Number (if a current customer)
For purposes of certification as a New Jersey Small Employer, an Employer is considered to be a Small Employer if the
Employer satisfies either of the definitions set forth below. Check which definition applies to the Employer named above.
 (A) Small Employer pursuant to N.J.S.A. 17B:27A-17 modified as required by 26 U.S.C. 4980H
This definition counts eligible employees. Eligible employee means a full-time employee who works a normal work week
of 25 or more hours. Eligible employee excludes sole proprietors, a partner in a partnership, independent contractors,
spouses, and employees working fewer than 25 hours per week, employees working on a temporary or substitute basis
and employees participating in an employee welfare arrangement pursuant to a collective bargaining agreement.
In connection with a Group Health Plan with respect to a Calendar Year and a Plan Year, any person, firm, corporation,
partnership, or political subdivision that is actively engaged in business that:
 employed an average of at least one, but not more than 50, eligible employees on business days during the
preceding Calendar Year, and
 employs at least one eligible employee on the first day of the Plan Year.
Eligible employees and any dependents to be covered must live, work or reside in the service area of the Group Health
Plan.
All persons treated as a single employer under subsection (b), (c), (m) or (o) of section 414 of the Internal Revenue Code
of 1986 shall be treated as one employer. In the case of an employer that was not in existence during the preceding
Calendar Year, the determination of whether the employer is a small or large employer shall be based on the average
number of Employees that it is expected that the employer will employ on business days in the current Calendar Year.
 (B) Small Employer pursuant to 45 C.F.R. 155.20
This definition counts employees. Employee means an individual who is an employee under the common law standard.
Employee excludes a sole proprietor, a partner in a partnership and a 2 percent S corporation shareholder as well as
immediate family members of such individuals. Employee also excludes a leased employee.
In connection with a Group Health Plan with respect to a Calendar Year and a Plan Year, an employer with a business
location in the state of New Jersey who:
 employed an average of at least one but not more than 50 employees on business days during the preceding
calendar year; and
 who employs at least one employee on the first day of the Plan Year.
Employees and any dependents to be covered must live, work or reside in the service area of the Group Health Plan.
All persons treated as a single employer under subsection (b), (c), (m) or (o) of section 414 of the Internal Revenue Code
of 1986 shall be treated as one employer. In the case of an Employer which was not in existence throughout the
preceding Calendar Year, the determination of whether such employer is a small or large employer shall be based on the
average number of employees that it is reasonably expected such Employer will employ on business days in the current
Calendar Year.
The following calculation must be used to determine if an employer employs at least 1 but not more than 50 employees.
For purposes of this calculation:
a) Employees working 30 or more hours per week are full-time employees and each full-time Employee counts as 1;
b) Employees working fewer than 30 hours per week are part-time and counted as the sum of the hours each part-time
Employee works per week multiplied by 4 and the product divided by 120 and rounded down to the nearest whole
number.
Add the number of full-time Employees to the number that results from the part-time employee calculation. If the sum is at
least 1 but not more than 50 the employer employs at least 1 but not more than 50 Employees.
Complete the following sections if the Employer is a Small Employer as defined in (A) or (B) above.
SGERCER 1 (2015/01)
1
HRINJ © 2015
Please indicate below the number of employees by work location/State. All employees must be included, regardless of
whether or not they currently have medical coverage and through whom that coverage is provided.
Work Location (list by State)
Full-time
Number of Employees
Part-time
COBRA or
State
Continuees
Other
The following information will be used to calculate the participation rate. Refer to the definition of “eligible employee” on
page 1.
Total # Eligible Employees
________
Total # Eligible Employees applying/enrolling for health benefits coverage
________
Total # Eligible Employees waiving health benefits coverage under the policy with
coverage under their spouse's or parent’s group coverage, Medicare, Medicaid, or
NJ FamilyCare or Tricare or any other group Health Benefits Plan through a
different employer
________
Total # Eligible Employees waiving health benefits coverage under the policy
with coverage under a Health Benefits Plan issued by another carrier and offered
by the small employer :
________
Please separately list the name(s) of the other carrier(s) and the number of employees covered under each:
___________________________________________________
________
___________________________________________________
________
Total # Eligible employees waiving health benefits coverage under the policy without
coverage under a spouse's or parent’s group coverage; Medicare, Medicaid, or
NJ FamilyCare or Tricare or any other Health Benefits Plan
Total # Employees in an ineligible class or classes
________
________
The following information will be used to determine how certain federal laws apply to the Small Employer.
Is your firm subject to Working Aged Provisions of federal law (TEFRA/DEFRA)?
Yes
No
(You may be subject to the law if you employed 20 or more employees for 20 weeks in the current or prior calendar year)
Is your firm subject to the requirements of the federal COBRA law?
Yes
No
(You may be subject to the law if you employed 20 or more employees during 50% or more of the working days during the
previous calendar year.)
What is the average number of employees you employed during the entire previous calendar year regardless of
whether they were eligible for enrolled for group coverage?
________
(When answering this question please count any employee for whom your company issues a W-2 and include full-time,
part-time and seasonal workers.)
SGERCER 1 (2015/01)
2
HRINJ © 2015
CERTIFICATION AS A SMALL EMPLOYER IN THE STATE OF NEW JERSEY
For a Group Health Benefits Plan
Please sign and date appropriate section indicating whether or not you meet the definition of a small employer which is an
“either or” definition. .
 I certify that I qualify as a Small Employer in the State of New Jersey using definition
(A)
(B)
AND
 I certify that the information provided to [Carrier] is true and complete. I understand that if the above information is not
complete or is not provided to [Carrier] in a timely manner, then health benefits coverage does not have to be offered
or continued. I further understand that incomplete or untrue information may void health benefits coverage.
 I certify that I have obtained and maintain a stand-alone pediatric dental plan for all employees and dependents enrolling
for health benefits coverage.
____________________________________________
Signature of Officer, Partner or Owner
________________________
Title
________________________________________________
Print Name of Officer, Partner or Proprietor
______________________
Date
________________________________________________
Signature of Witness
______________________
Date
 I certify that I am NOT a Small Employer in the State of New Jersey as defined in either (A) OR (B)above.
____________________________________________
Signature of Officer, Partner or Owner
________________________
Title
________________________________________________
Print Name of Officer, Partner or Proprietor
______________________
Date
________________________________________________
Signature of Witness
______________________
Date
Any person who includes any false or misleading information on an application or enrollment form or
certification for a health benefits plan is subject to criminal and civil penalties.
SGERCER 1 (2015/01)
3
HRINJ © 2015
Complete this section if you have certified that the Employer is a Small Employer using definition (A) or (B)
* CENSUS INFORMATION
Please include the following persons in the following list:
a
employees, owners, partners, and officers who are actively working for the employer on a regular basis, and are paid by the
employer on a regular basis, whether or not they are eligible to be covered under the policy.
b
employees, owners, partners and officers who are not working, but who are currently covered under the employer's health benefits
plan for reasons such as continuation of coverage or total disability.
Please use the following letters to indicate Status:
O:
F:
P:
T:
S:
D:
C:
U.
Owner, partner or officer
Full-time employee who works 25 or more hours per week
Part-time employee who works less than 25 hours per week
Temporary employee
Seasonal employee
Totally Disabled employee
Continuee under state or federal law
Employee participating in an employee welfare arrangement established pursuant to a collective bargaining agreement.
Name
Job Title
Date of
Employment
Hours
worked per
week
Status
Work Location
(State)
Date of
Birth
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
*If additional space is needed, attach a separate sheet.
SGERCER 1 (2015/01)
4
HRINJ © 2015
HRINJ LATE SUBMISSION FORM
Dear Producer:
This acknowledgement must be completed, signed and submitted to Health Republic Insurance
of New Jersey’s Small Group Underwriting Department along with their completed group
enrollment paperwork and first month’s premium if the group department will be receiving the
group application and enrollment forms less than five days prior to the requested effective
date. You must inform the Group Administrator that their group’s application and coverage will
take up to 10 business days to process once received.
As a condition of our acceptance of this application, given its late submission, please review the
following statement and have the group administrator sign in the space provided.
As the group administrator of____________________________________(the “Group”), I certify
that the Group agrees and acknowledges that it is requesting a coverage effective date that will
result in Health Republic Insurance of New Jersey receiving the group’s application and
paperwork less than five business days prior to the requested coverage effective date. If our
request for insurance and requested effective date are approved, we acknowledge that delivery
of our identification cards and system activation may occur after our effective date.
The submission of this form is not a guarantee of late acceptance of the group’s application.
Group Name: ________________________
Requested Effective Date: ________________________
Group Administrators Name: _______________________________
Signature: ___________________________________
Date: ________________________________________
Please submit this form with your completed group enrollment paperwork and payment:


Fax: 201.308.8605
Mail: 570 Broad Street, Suite 1100, Newark, NJ 07102
Thank you for your cooperation!
HRINJ New Business Processing Unit
SG-UND-LS 1 (2015/01)
HRINJ © 2015
GROUP ENROLLMENT/CHANGE REQUEST
Group Information – to be completed by Employer:
Health Republic Insurance of New Jersey
Group Name:
Group Number:
Class Code:
4. COVERAGE
CONTINUATION
3. OTHER
CHANGE
2. REMOVE
1. ADD
A. Type of Activity – to be completed by Employer. Refer to instructions on page 5 before completing this form. Print clearly.
Activity – Check all that apply
Effective Date/
Date of Hire/Reason for Change
Date of Event
Enrollment of a new Enrollee
_____/_____/_____
Date of Hire: _____/_____/_____
Add Spouse/Civil Union Partner
_____/_____/_____
________________________________________________________
Add Domestic Partner
_____/_____/_____
________________________________________________________
Add Dependent Child
_____/_____/_____
________________________________________________________
Add Over-Age Child as a Dependent Under 31(and complete
_____/_____/_____
________________________________________________________
section A 4)
Employee Withdrawal/Termination
_____/_____/_____
________________________________________________________
Remove Spouse/Civil Union Partner
_____/_____/_____
________________________________________________________
Remove Domestic Partner
_____/_____/_____
________________________________________________________
Remove Dependent Child
_____/_____/_____
________________________________________________________
Remove Over-Age Child as a Dependent Under 31
_____/_____/_____
________________________________________________________
Name Change
Change Plan
Other
Add/Change Office ID Numbers: Primary/OB/Gyn/ Dentist
For Employee
Total Disability*
COBRA/NJSGC
Length of Continuation (in months):
18
29
Date of Loss of Coverage: ___/___/___
Qualifying Event #:____________**
Date of Qualifying Event: ___/___/___
Billing:
Group
Home (Section B)
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
For Dependent or Over-age Child
COBRA/NJSGC
Length of Continuation (in months):
18
36
Loss of Coverage: ___/___/___
Qualifying Event #:__________________**
Date: ___/___/___
Dependent Under 31
Qualifying Event #:__________________**
Billing:
Group***
Home (what address?)
*Attach proof of disability
*Civil union partners are eligible to make an
Section B OR
election pursuant to NJSGC, if applicable.
Section F
**Qualifying event #s: see list in Instructions. ***Billing through the group for a Dependent Under 31 Continuation Election requires agreement by the employer at
Section J.
NJ-HINT-Group
For Spouse/Civil Union Partner*
Length of Continuation (in months):
18
36
Date of Loss of Coverage: ___/___/___
Qualifying Event #:_________________**
Date of Qualifying Event: ___/___/___
Billing:
Group
Home (what address?)
Section B OR
Section E
1
HRINJ © 2016
B. Employee Information – to be
completed by the Employee
Name (Last, First, MI):
SSN:
Home
Work
Birthdate (mm/dd/yyyy):
Street/Apt:________________________________________________________________________________________
Street/Apt:________________________________________________________________________________________
City:___________________________________________________ State:_____ Zip Code: _____________________
Employer Name:__________________________________________________________________________________
Address:__________________________________________________________________________________________
City:___________________________________________________ State:_____ Zip Code: ______________________
Male
Female
Phone: (_____)________________
Email: _______________________________
Phone: (_____)__________________
Email:
_________________________________
Employment Date: _____/_____/_____
Hours worked per week:_________
Activity
Add
Remove
Continuation
Other Change If a name change, indicate prior name:
Primary Loc #:________________________________________________________________
NPI #:
Current Patient:
Yes
address:
zip+4
No
Ob/Gyn Loc #:________________________________________________________________
NPI #:
Current Patient:
Yes
address:
zip+4
No
Dentist Loc #:________________________________________________________________
NPI #:
Current Patient:
Yes
address:
zip+4
No
Other Health Coverage?
Yes
No If yes:
Other Rx Coverage?
Yes
No If yes:
Payer Name: ____________________________________________________________ Payer Name: ____________________________________________________________
Policy #: ________________________________________
Policy #: ___________________________________________
Medicare ID#, if any:
Medicare ID#, if any:
NJ-HINT-Group
2
HRINJ © 2016
C. Plan Option – to be completed by the Employee Check one
Health Republic Full Access Prime:
Health Republic Full Access Pure:
Bronze
Bronze
Silver
Silver
Gold
Gold
Health Republic Active Access Spotlight
Plan:
Bronze
Silver
Platinum
Health Republic Full Access Solid:
Bronze (HSA)
Silver (HSA)
Platinum
Health Republic CentraState Community Plan:
Bronze
Gold
Stand Alone Pediatric Dental (SAPD): Federal law
requires coverage for pediatric dental benefits.
Because the Health Republic Medical Plan Options do
not contain pediatric dental benefits, you must buy
pediatric dental benefits separately and must provide
assurance that you have, or will obtain a Marketplacecertified SAPD plan.
Health Republic Full Access Core:
I have purchased or am purchasing a Marketplacecertified SAPD plan with another carrier to be effective
when the medical coverage is effective. I agree to
provide information demonstrating this coverage
immediately to HRINJ if requested, that may include the
evidence of coverage, the name of the issuer and
applicable policy number. I attest that this information is
accurate.
Silver
Gold
Platinum
D. Other Individuals Covered – to be completed by the Employee. Identify individuals other than yourself for whom you are adding/changing/removing/continuing coverage.
Attach additional pages if necessary, with your signature and dated. Attach proof of disability.
1. Spouse; Domestic or Civil Union
2.Child
3. Child
4. Child
Partner
Add
Remove
Add
Remove
Add
Remove
Add
Remove
Other Continue Spouse
Other
Continue
Other
Continue
Other
Continue
Continue CU Partner (NJSGC)
Name (last, first, MI)
Name (last, first, MI)
Name (last, first, MI)
Name (last, first, MI)
L:________________________________
L:_________________________________
L:_________________________________
L:_______________________________
F:________________________________
MI:
Birthdate (mm/dd/yyyy):
F:_________________________________
MI:
Birthdate (mm/dd/yyyy):
F:_________________________________
MI:
Birthdate (mm/dd/yyyy):
F:_______________________________
MI:
Birthdate (mm/dd/yyyy):
NJ-HINT-Group
3
HRINJ © 2016
Male
Female
Male
Female
Male
Female
Male
Female
Social Security Number:
Social Security Number:
Social Security Number:
Social Security Number:
Other Health Coverage
Yes
No
If yes:
Payer Name:
_________________________________
Policy #: _________________________
Medicare ID #:
Other Health Coverage
Yes
No
If yes:
Payer Name:
___________________________________
Policy #: ___________________________
Medicare ID #:
Other Health Coverage
Yes
No
If yes:
Payer Name:
___________________________________
Policy #: ___________________________
Medicare ID #:
Other Health Coverage
Yes
No
If yes:
Payer Name:
_________________________________
Policy #: _________________________
Medicare ID #:
Other Rx Coverage:
Yes
No
If yes:
Payer Name:
__________________________________
Other Rx Coverage:
Yes
No
If yes:
Payer Name:
___________________________________
Other Rx Coverage:
Yes
No
If yes:
Payer Name:
___________________________________
Other Rx Coverage:
Yes
No
If yes:
Payer Name:
_________________________________
Policy #: __________________________
Medicare ID #:
Policy #: ___________________________
Medicare ID #:
Policy #: ___________________________
Medicare ID #:
Policy #: _________________________
Medicare ID #:
Primary Care Provider:
NPI#:____________________
Primary Care Provider:
NPI:______________________
Primary Care Provider:
NPI#:_____________________
Primary Care Provider:
NPI#:______________________
Address:___________________________
Address:____________________________
Address:____________________________
Address:__________________________
__________________________________
___________________________________
___________________________________
_________________________________
______________zip+4_______________
Current Patient? Yes
No
Ob/Gyn Office
NPI#:______________________
_______________ zip+4______________
Current Patient?
Yes
No
Ob/Gyn Office
NPI#:____________________
_______________ zip+4_______________
Current Patient? Yes
No
Ob/Gyn Office
NPI#:______________________
__________________ zip+4_ ________
Current Patient? Yes
No
Ob/Gyn Office
NPI#:______________________
Address:___________________________
Address:____________________________
Address:____________________________
Address:__________________________
__________________________________
___________________________________
___________________________________
_________________________________
____________________ zip+4_________
Current Patient? Yes
No
NA
____________________ zip+4__________
Current Patient?
Yes
No
NA
___________________ zip+4 _________
Current Patient?
Yes
No
NA
______________________ zip+4______
Current Patient? Yes No
NA
NJ-HINT-Group
4
HRINJ © 2016
Employed?
Yes
No
If yes, complete Section E1
If last name is different from Employee’s,
please explain:
If last name is different from Employee’s,
please explain:
If last name is different from
Employee’s, please explain:
___________________________________
___________________________________
_________________________________
___________________________________ ___________________________________ _________________________________
Home or billing address same as
Living with Employee?
Living with Employee?
Living with Employee?
Employee?
Yes
No
Yes
No
Yes
No
Yes
No
If NO, complete Section E2
If NO, complete Section F
If NO, complete Section F
If NO, complete Section F
1. Employer Name:________________________________________________________________________________
E. 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:__________________________________________________________________________
F. 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):________________________________________________________________
Street/Apt:_______________________________________________________________
Street/Apt:_______________________________________________________________
City, State, Zip Code: _____________________________________________________
Reason:_________________________________________________________________
Name(s):_______________________________________________________________
Street/Apt:_____________________________________________________________
Street/Apt:_____________________________________________________________
City, State, Zip Code:_____________________________________________________
Reason:________________________________________________________________
G. 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
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
H. Employee Signature
Enrollment/Change Request form. I authorize deductions from my earnings for any contributions required from me.
I. Over-Age Child’s
Signature
Signature: _________________________________________________________________________ Date: ________________________________
I represent that all the information supplied in this application regarding the Dependent Under 31 Continuation Election is true and complete. I
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 31 Continuation Election.
J. Employer Verification
Signature: _________________________________________________________________________ Date: ________________________________
The requested activity is believed eligible and is approved by the Employer. In addition, the Employer consents to payroll deduction for Dependent
Under 31 Continuation Election:
Yes
No
Employer Representative: _____________________________________________________ Date: _______________________________________
Representative’s Title: _________________________________________________________
NJ-HINT-Group
5
HRINJ © 2016
CONDITIONS OF ENROLLMENT -- APPLICANT ACKNOWLEDGEMENTS AND AGREEMENTS
On behalf of myself and the dependents listed in this Enrollment/Change Request form, I acknowledge that:
1. I authorize any physician or medical professional, hospital, clinic or other medical care institution, carrier, consumer reporting agency, and any employer to give Health
Republic Insurance of New Jersey, or any consumer reporting agency acting on behalf of Health Republic Insurance of New Jersey, information pertaining to employment,
other health coverage, and medical advice, treatment or supplies for any physical or mental condition relevant to me or a minor dependent applying for coverage. I agree
that this authorization shall be valid for 30 months from the date I sign this Enrollment/Change Request form, unless revoked at an earlier date.
2. I agree that, if I revoke this authorization before it expires, such revocation shall not affect any action that Health Republic Insurance of New Jersey has taken in reliance
on the authorization.
3. I understand I may receive a copy of this authorization if I request one.
4. I agree Health Republic Insurance of New Jersey will provide coverage in accordance with the terms of the contract for the group plan.
5. I agree that the provision of coverage and benefits is contingent upon payment of premiums and may be terminated in accordance with the terms of the group plan if
premiums are not paid timely. I authorize my Employer to withhold payments from my wages as contribution to the premium, as appropriate.
INSTRUCTIONS
Employers – You must complete the Employer Group Information and sections A and J in order for this
Qualifying Events
application to be processed.
COBRA and NJSGC
C1. Termination of job or reduction in hours
Employees – You must complete sections B through H and submit the signature of each Over-Age Child for
C2. Employee enrollment in Medicare (COBRA only)
which a Dependent Under 31 Continuation Election is made in accordance with Section I in order for this
C3. Divorce (COBRA/NJSGC); civil union dissolution (NJSGC)
application to be processed.
C4. Death of employee
C5. Loss of dependent child status under the plan
 Please PRINT except when a signature is requested.
 If a dependent is disabled and you want to continue his or her coverage beyond age 26, you do not have to C6. Disability (occurring subsequent to another qualifying event)
Dependent Under 31
make a COBRA/NJSGC or Dependent Under 31 election. Instead, select “Other” in Section A3, and
D1. Loss of dependent status and otherwise eligible
attach proof of disability.
D2. Reestablish eligibility: residency
 For provider addresses, include the zip code plus the four digit extension (11 digits)
D3. Reestablish eligibility: nonresident full-time student
 You can obtain the providers’ correct names and addresses from the appropriate provider directory. You
D4. Reestablish eligibility: change in marital status
may also obtain each provider’s NPI number from the online provider directory at:
D5. Reestablish eligibility: change in parental status
newjersey.healthrepublic.us/providersearch or by contacting the provider directly. Providers with
multiple office locations and individual providers who belong to more than one practice or provider entity D6. Reestablish eligibility: termination of other coverage
may have more than one NPI number. You should confirm the correct NPI number for the specific
provider and office location where you will be seen by contacting that office directly.
MISREPRESENTATIONS
Any person who includes any false or misleading information on an application or enrollment form or certification for a health benefits plan is subject to criminal and civil
penalties.
NJ-HINT-Group
6
HRINJ © 2016
2016 Active Access Spotlight
BRONZE
Tier 1
DEDUCTIBLE
OUT-OF-POCKET
MAXIMUM
SILVER
Tier 2
Tier 1
Tier 2
Individual
$2,500
$2,000
PLATINUM
Tier 1
Tier 2
$0
Family
$5,000
$4,000
$0
Individual
$6,850
$6,000
$1,250
Family
$13,700
$12,000
$2,500
PRIMARY CARE VISIT
SPECIALIST VISIT
No referrals required
PREVENTIVE CARE VISIT
PRENATAL AND
POSTNATAL CARE
PEDIATRIC VISION SERVICES
$10 Copay
50% Coinsurance
after Deductible after Deductible
$75 Copay after Deductible
$10 Copay
40% Coinsurance
$50 Copay
$10 Copay
20% Coinsurance
$10 Copay
Plan pays 100%
Tier 1
$25 Copay
$25 Copay
$5 Copay
Tier 2
50% Coinsurance after Deductible
$50 Copay
$10 Copay
Tier 3
50% Coinsurance after Deductible
$75 Copay
$15 Copay
EMERGENCY ROOM
Copay waived if
admitted within 24 hours
50% Coinsurance
after Deductible
$100 Copay, then
Deductible and
40% Coinsurance
$100 Copay
URGENT CARE VISIT
$75 Copay after Deductible
$50 Copay
$10 Copay
$500/day after Deductible
(up to 5 days)
50% Coinsurance
after Deductible
$500/day
(up to 5 days)
40% Coinsurance
after Deductible
$100/day
(up to 5 days)
PRESCRIPTION DRUGS
INPATIENT HOSPITAL
SERVICES
Facility Fee
Physician/
Surgeon Fee
Facility Fee
OUTPATIENT SURGERY
MENTAL HEALTH &
SUBSTANCE ABUSE
SERVICES
Physician/
Surgeon Fee
50% Coinsurance
after Deductible
$50 Copay
Inpatient
$500/day after Deductible
(up to 5 days)
40% Coinsurance
after Deductible
$500/day after Deductible
(up to 5 days)
Outpatient
$50 Copay after Deductible
$50 Copay
20% Coinsurance
$10 Copay
20% Coinsurance
$100/day
(up to 5 days)
$10 Copay
Active Access Spotlight is not available for enrollment to
individuals and small groups residing in Salem County
This is only a summary. More details are available by
visiting newjersey.healthrepublic.us or calling 888.990.5706
570 Broad Street, Suite 1100, Newark, NJ 07102 | Tel: 888 990 5706 | newjersey.healthrepublic.us
Coverage underwritten by Freelancers Consumer Operated and Oriented Program of New Jersey, Inc.
00180 1115
2016 CentraState Community Plan
Tier 1
DEDUCTIBLE
OUT-OF-POCKET
MAXIMUM
BRONZE
Individual
$2,500
Family
$5,000
Individual
$6,850
Family
$13,700
PRIMARY CARE VISIT
SPECIALIST VISIT
No referrals required
PREVENTIVE CARE VISIT
PRENATAL AND
POSTNATAL CARE
PEDIATRIC VISION SERVICES
PRESCRIPTION DRUGS
Tier 2
$50 Copay
after Deductible
50% Coinsurance
after Deductible
$75 Copay
after Deductible
50% Coinsurance
after Deductible
Plan pays 100%
Tier 1
$25 Copay after Deductible
Tier 2
50% Coinsurance after Deductible
Tier 3
50% Coinsurance after Deductible
EMERGENCY ROOM
Copay waived if
admitted within 24 hours
50% Coinsurance after Deductible
URGENT CARE VISIT
$75 Copay after Deductible
INPATIENT HOSPITAL
SERVICES
Facility Fee
Physician/
Surgeon Fee
$500/day
after Deductible
(up to 5 days)
50% Coinsurance
after Deductible
50% Coinsurance after Deductible
Facility Fee
OUTPATIENT SURGERY
50% Coinsurance after Deductible
Physician/
Surgeon Fee
MENTAL HEALTH &
SUBSTANCE ABUSE
SERVICES
Inpatient
$500/day
after Deductible
(up to 5 days)
Outpatient
$50 Copay
after Deductible
50% Coinsurance
after Deductible
The CentraState Community Plan is only available for enrollment to individuals and
small groups residing in Monmouth County and select areas of Mercer, Middlesex and Ocean counties.
This is only a summary. More details are available by
visiting newjersey.healthrepublic.us or calling 888.990.5706
570 Broad Street, Suite 1100, Newark, NJ 07102 | Tel: 888 990 5706 | newjersey.healthrepublic.us
Coverage underwritten by Freelancers Consumer Operated and Oriented Program of New Jersey, Inc.
00175 1115
2016 Full Access Core
DEDUCTIBLE
SILVER
GOLD
PLATINUM
Individual
$2,500
$1,500
$750
Family
$5,000
$3,000
$1,500
Individual
$5,000
$3,500
$1,500
Family
$10,000
$7,000
$3,000
PRIMARY CARE VISIT
$25 Copay
$10 Copay
$5 Copay
SPECIALIST VISIT
No referrals required
$50 Copay
$25 Copay
$10 Copay
OUT-OF-POCKET
MAXIMUM
PREVENTIVE CARE VISIT
PRENATAL AND
POSTNATAL CARE
PEDIATRIC VISION SERVICES
Plan pays 100%
Tier 1
$25 Copay
$10 Copay
$5 Copay
Tier 2
$50 Copay
$25 Copay
$10 Copay
Tier 3
40% Coinsurance
after Deductible
30% Coinsurance
after Deductible
20% Coinsurance
after Deductible
EMERGENCY ROOM
Copay waived if
admitted within 24 hours
$100 Copay, then
Deductible and
40% Coinsurance
$100 Copay, then
Deductible and
30% Coinsurance
$100 Copay
URGENT CARE VISIT
$50 Copay
$25 Copay
$10 Copay
40% Coinsurance
after Deductible
30% Coinsurance
after Deductible
20% Coinsurance
after Deductible
40% Coinsurance
after Deductible
30% Coinsurance
after Deductible
20% Coinsurance
after Deductible
Inpatient
40% Coinsurance
after Deductible
30% Coinsurance
after Deductible
20% Coinsurance
after Deductible
Outpatient
$50 Copay
$25 Copay
$10 Copay
PRESCRIPTION DRUGS
INPATIENT HOSPITAL
SERVICES
Facility Fee
Physician/
Surgeon Fee
Facility Fee
OUTPATIENT SURGERY
MENTAL HEALTH &
SUBSTANCE ABUSE
SERVICES
Physician/
Surgeon Fee
This is only a summary. More details are available by
visiting newjersey.healthrepublic.us or calling 888.990.5706
570 Broad Street, Suite 1100, Newark, NJ 07102 | Tel: 888 990 5706 | newjersey.healthrepublic.us
Coverage underwritten by Freelancers Consumer Operated and Oriented Program of New Jersey, Inc.
00176 1115
2016 Full Access Prime
DEDUCTIBLE
OUT-OF-POCKET
MAXIMUM
BRONZE
SILVER
GOLD
Individual
$2,450
$2,000
$1,500
Family
$4,900
$4,000
$3,000
Individual
$6,850
$5,000
$3,000
Family
$13,700
$10,000
$6,000
$50 Copay
after Deductible
First 4 visits covered 100%
$25 Copay after Deductible
for subsequent visits
Plan pays 100%
$75 Copay
after Deductible
$50 Copay
after Deductible
$25 Copay
after Deductible
PRIMARY CARE VISIT
SPECIALIST VISIT
No referrals required
PREVENTIVE CARE VISIT
PRENATAL AND
POSTNATAL CARE
PEDIATRIC VISION SERVICES
Plan pays 100%
50% Coinsurance after
Deductible
$25 Copay
after Deductible
$50 Copay
after Deductible
40% Coinsurance
after Deductible
$15 Copay
after Deductible
$25 Copay
after Deductible
$50 Copay
after Deductible
EMERGENCY ROOM
Copay waived if
admitted within 24 hours
Deductible, then
$100 Copay and
50% Coinsurance
Deductible, then
$100 Copay and
40% Coinsurance
Deductible, then
$100 Copay and
30% Coinsurance
URGENT CARE VISIT
$75 Copay
after Deductible
$50 Copay
after Deductible
$25 Copay
after Deductible
40% Coinsurance
after Deductible
30% Coinsurance
after Deductible
50% Coinsurance
after Deductible
40% Coinsurance
after Deductible
30% Coinsurance
after Deductible
Inpatient
$500/day after Deductible
(up to 5 days)
40% Coinsurance
after Deductible
30% Coinsurance
after Deductible
Outpatient
$50 Copay
after Deductible
$50 Copay
after Deductible
$25 Copay
after Deductible
Tier 1
PRESCRIPTION DRUGS
Tier 2
Tier 3
INPATIENT HOSPITAL
SERVICES
$500/day after Deductible
(up to 5 days)
Physician/
50% Coinsurance
Surgeon Fee
after Deductible
Facility Fee
Facility Fee
OUTPATIENT SURGERY
MENTAL HEALTH &
SUBSTANCE ABUSE
SERVICES
Physician/
Surgeon Fee
The Full Access Prime Gold Plan is only available for group coverage
This is only a summary. More details are available by
visiting newjersey.healthrepublic.us or calling 888.990.5706
570 Broad Street, Suite 1100, Newark, NJ 07102 | Tel: 888 990 5706 | newjersey.healthrepublic.us
Coverage underwritten by Freelancers Consumer Operated and Oriented Program of New Jersey, Inc.
00177 1115
2016 Full Access Pure
BRONZE
SILVER
GOLD
PLATINUM
Individual
$2,500
$2,000
$1,800
$0
Family
$5,000
$4,000
$3,600
$0
Individual
$6,850
$5,000
$3,000
$2,000
Family
$13,700
$10,000
$6,000
$4,000
PRIMARY CARE VISIT
$50 Copay after Deductible
$25 Copay
$15 Copay
$10 Copay
SPECIALIST VISIT
No referrals required
$75 Copay after Deductible
$75 Copay
$50 Copay
$25 Copay
$10 Copay
$5 Copay
$25 Copay
$10 Copay
$50 Copay
$25 Copay
DEDUCTIBLE
OUT-OF-POCKET
MAXIMUM
PREVENTIVE CARE VISIT
PRENATAL AND
POSTNATAL CARE
PEDIATRIC VISION SERVICES
Tier 1
PRESCRIPTION DRUGS
Tier 2
Tier 3
Plan pays 100%
50% Coinsurance
after Deductible, up to
$100 maximum
50% Coinsurance
after Deductible, up to
$250 maximum
40% Coinsurance
after Deductible, up to
$100 maximum
40% Coinsurance
after Deductible, up to
$250 maximum
50% Coinsurance
after Deductible, up to
$500 maximum
40% Coinsurance
after Deductible, up to
$500 maximum
EMERGENCY ROOM
Copay waived if
admitted within 24 hours
$100 Copay
after Deductible
URGENT CARE VISIT
$75 Copay after Deductible
$75 Copay
$50 Copay
$25 Copay
$500/day after Deductible
(up to 5 days)
50% Coinsurance
after Deductible
40% Coinsurance
after Deductible
30% Coinsurance
after Deductible
20% Coinsurance
50% Coinsurance
after Deductible
40% Coinsurance
after Deductible
$50 Copay
$25 Copay
$500/day after Deductible
(up to 5 days)
40% Coinsurance
after Deductible
INPATIENT HOSPITAL
SERVICES
Facility Fee
Physician/
Surgeon
Facility Fee
OUTPATIENT SURGERY
MENTAL HEALTH &
SUBSTANCE ABUSE
SERVICES
Physician/
Surgeon
Inpatient
Outpatient $50 Copay after Deductible
$100 Copay
30% Coinsurance
after Deductible
30% Coinsurance
after Deductible
20% Coinsurance
20% Coinsurance
$50 Copay
This is only a summary. More details are available by
visiting newjersey.healthrepublic.us or calling 888.990.5706
570 Broad Street, Suite 1100, Newark, NJ 07102 | Tel: 888 990 5706 | newjersey.healthrepublic.us
Coverage underwritten by Freelancers Consumer Operated and Oriented Program of New Jersey, Inc.
$25 Copay
00178 1115
2016 Full Access Solid
DEDUCTIBLE
OUT-OF-POCKET
MAXIMUM
Individual
BRONZE (HSA)
SILVER (HSA)
GOLD
$2,450
$2,000
$1,000
Family
$4,900
$4,000
$2,000
Individual
$6,450
$5,000
$2,500
Family
$12,900
$10,000
$5,000
50% Coinsurance
after Deductible
40% Coinsurance
after Deductible
30% Coinsurance
after Deductible
50% Coinsurance
after Deductible
40% Coinsurance
after Deductible
30% Coinsurance
after Deductible
PRIMARY CARE VISIT
SPECIALIST VISIT
No referrals required
PREVENTIVE CARE VISIT
PRENATAL AND
POSTNATAL CARE
PEDIATRIC VISION SERVICES
Plan pays 100%
Tier 1
50% Coinsurance
after Deductible
40% Coinsurance
after Deductible
30% Coinsurance
after Deductible
EMERGENCY ROOM
Copay waived if
admitted within 24 hours
50% Coinsurance
after Deductible
Deductible, then
$100 Copay and
40% Coinsurance
Deductible, then
$100 Copay and
30% Coinsurance
URGENT CARE VISIT
50% Coinsurance
after Deductible
40% Coinsurance
after Deductible
30% Coinsurance
after Deductible
$500/day after Deductible
(up to 1 day)
50% Coinsurance
after Deductible
40% Coinsurance
after Deductible
30% Coinsurance
after Deductible
50% Coinsurance after
Deductible
40% Coinsurance
after Deductible
30% Coinsurance
after Deductible
$500/day after Deductible
(up to 1 day)
50% Coinsurance
after Deductible
40% Coinsurance
after Deductible
30% Coinsurance
after Deductible
PRESCRIPTION DRUGS
Tier 2
Tier 3
INPATIENT HOSPITAL
SERVICES
Facility Fee
Physician/
Surgeon Fee
Facility Fee
OUTPATIENT SURGERY
MENTAL HEALTH &
SUBSTANCE ABUSE
SERVICES
Physician/
Surgeon Fee
Inpatient
Outpatient
This is only a summary. More details are available by
visiting newjersey.healthrepublic.us or calling 888.990.5706
570 Broad Street, Suite 1100, Newark, NJ 07102 | Tel: 888 990 5706 | newjersey.healthrepublic.us
Coverage underwritten by Freelancers Consumer Operated and Oriented Program of New Jersey, Inc.
00179 1115
2016 Vital Plan
CATASTROPHIC
DEDUCTIBLE
OUT-OF-POCKET
MAXIMUM
Individual
$6,850
Family
$13,700
Individual
$6,850
Family
$13,700
PRIMARY CARE VISIT
SPECIALIST VISIT
No referrals required
PREVENTIVE CARE VISIT
PRENATAL AND
POSTNATAL CARE
PEDIATRIC VISION SERVICES
First 3 visits covered 100%
Subsequent visits covered 100% after deductible
Covered 100% after deductible
Plan pays 100%
Tier 1
PRESCRIPTION DRUGS
Tier 2
Covered 100% after deductible
Tier 3
EMERGENCY ROOM
Covered 100% after deductible
URGENT CARE VISIT
Covered 100% after deductible
INPATIENT HOSPITAL
SERVICES
Facility Fee
Physician/
Surgeon Fee
Covered 100% after deductible
Facility Fee
OUTPATIENT SURGERY
MENTAL HEALTH &
SUBSTANCE ABUSE
SERVICES
Physician/
Surgeon Fee
Inpatient
Outpatient
Covered 100% after deductible
Covered 100% after deductible
Vital is available for individual enrollment only
This is only a summary. More details are available by
visiting newjersey.healthrepublic.us or calling 888.990.5706
570 Broad Street, Suite 1100, Newark, NJ 07102 | Tel: 888 990 5706 | newjersey.healthrepublic.us
Coverage underwritten by Freelancers Consumer Operated and Oriented Program of New Jersey, Inc.
00181 1115
Daviss Vision En
nrollment Application
Employeee (Member) Info
ormation (Pleasee Print)
Employer//Group Name
Reason for Application:
A
Addition
Reinstate
Change
COBRA
Check Type oof Coverage:
Employyee Only
Employyee and Spouse or Doomestic Partner
Family
Employyee & Child
Employyee & Children
Termination
Waive Coverage
Employee (Member) First Nam
me / Middle Initial / Last
L Name
Mailing Adddress
City
Employee (Member) Identificaation Number
Month
M
Effective Datee:
Day
State
Zip Code
To be complete by Account Administrator or Hu
uman
Resourcces representative only Employeee Status
Year
Acttive
Hourly
Salaried
Rettired (Date) _______
__
Employee Hiire Date
Month
h
Day
Employee Phone Number
Group N
Number
Payroll Code
Year
Subgrouup Code
Plan Code
Please in
ndicate the change(s) that you neeed to make to your
y
record:
Change of Name
Change of
Address
Change of Phone
Chaange of Birthdate
Chaange of Effective
Date
Complette If Applicable
Change of Reeport
Code
Existing
New
First Name/Middlle Initial/Last Namee
Self
Spouse
Dom. Partner
Child
Other
Child
Other
Child
Other
Please rreturn completed form to:
Davis Vission CDM – Manual Eligibility
E
Fax: 1-8800-783-9046
Coverage underwritten by HM Life Insurance Company
Chan
nge in Group #
Existing
g
New
y
Social Security
Number
Change
Change of E
Enrollment Status to:
Employee Only
Employee and Spouuse/ Domestic Partneer
Employee and Chilld
Effective Date off
Change
M
MM
DD
YY
Y
Sex
M/F
Employee/C
Children
Family
Birth Date *
Check If
dent
Stud
overr 19
Disabled
MM
DD
YY
Add
Term
Add
Term
Add
Term
Add
Term
Add
Term
Member/E
Employee Signatu
ure
I certify that this enrollm
ment information is truee and correct
*Required
*
for all memb
bers and dependents Datee
Updated 11/18/15 00187 1115 2016 HRINJ/Davis Vision Fashion Plan
FOR SMALL GROUPS
Vision benefits available to you through our partnership with Davis Vision
BENEFIT
FREQUENCY
ONCE EVERY…
IN-NETWORK
COPAY
EYE EXAMINATION
12 months
$0
SPECTACLE LENSES
12 months
$0
FRAME
12 months
$0
Covered in Full Frames: Any Fashion level frame from Davis Vision’s Collection*
(retail value, up to $100).
OR, Frame Allowance: $100 toward any frame from provider plus 20% off any
balance. No copay required.
CONTACT LENS EVALUATION,
FITTING & FOLLOW UP CARE
12 months
$0
Standard, Soft Contacts: 15% discount
Specialty Contacts**: 15% discount
CONTACT LENSES
in lieu of eyeglasses
12 months
$10
Contact Lens Allowance: $100 allowance twoard any contacts from provider's supply
plus 15% off balance. No copay required.
OR, Medically Necessary Contacts: Covered in full with prior approval.
OPTIONAL FRAMES,
LENS TYPES AND COATINGS
Fashion
Designer
Premier
TINTING OF PLASTIC LENSES
OVERSIZE LENSES
SCRATCH-RESISTANT COATING
ULTRAVIOLET COATING
Standard
ANTI-REFLECTIVE
Premium
COATING
Ultra
POLYCARBONATE LENSES
HIGH-INDEX LENSES
Standard
PROGRESSIVE LENSES Premium
Ultra
POLARIZED LENSES
PHOTOCHROMIC LENSES
(i.e. Transitions®, etc.)^^
Single
Vision
SCRATCH PROTECTION
PLAN
Multifocal
Lenses
DAVIS VISION
COLLECTION FRAMES
MEMBER PRICE
$0
$15
$40
$15
$0
$0
$15
$40
$55
$69
$0^ - $35
$60
$65
$105
$140
$75
$65
$20
$40
2016 Vision Coverage Rates
IN-NETWORK COVERAGE
Covered in full. Includes dilation when professionally indicated.
Clear plastic lenses in any single vision, bifocal, trifocal or lenticular prescription.
Covered in full. (See below for additional lens options and coatings.)
To find participating providers, please visit
davisvision.com or call 1.877.923.2847 and
enter client code 3165.
* The Davis Vision Collection is available at most
participating independent provider locations.
** Including, but not limited to toric, multifocal and gas
permeable contact lenses.
^ For dependent children, monocular patients and patients
with prescriptions of +/- 6.00 diopters or greater.
^^Transitions® is a registered trademark of Transitions
Optical Inc.
Please note: Your provider reserves the right to not dispense
materials until all applicable member costs, fees and
copayments have been collected. Contact lenses: Routine
eye examinations do not include professional services for
contact lens evaluations. Any applicable fees above the
evaluation and fi tting allowance are the responsibility of the
member. If contact lenses are selected and fitted, they may
not be exchanged for eyeglasses. Progressive lenses: If you
are unable to adapt to progressive addition lenses you have
purchased, conventional bifocals will be supplied at no
additional cost; however, your copayment is nonrefundable.
May not be combined with other discounts or offers. Please
be advised these lens options and copayments apply to
in-network benefits.
Member Only = $7.85
Member + 1 = $14.15
Member + Family = $22.00
00185 1115
570 Broad Street, Suite 1100, Newark, NJ 07102 | Tel: 888 990 5706 | newjersey.healthrepublic.us
Coverage underwritten by HM Life Insurance Company
2016 HRINJ/Davis Vision Premier Plan
Vision benefits available to you through our partnership with Davis Vision
Benefits available to children up to age 19
FREQUENCY
ONCE EVERY…
IN-NETWORK
COPAY
EYE EXAMINATION
12 months
$0
SPECTACLE LENSES
12 months
$0
BENEFIT
IN-NETWORK COVERAGE
Covered in full. Includes dilation when professionally indicated.
Clear plastic lenses in any single vision, bifocal, trifocal or lenticular prescription.
Covered in full. (See below for additional lens options and coatings.)
FRAME
12 months
$0
Covered in Full Frames: Any Fashion, Designer or Premier level frame from
Davis Vision’s Collection* (retail value, up to $225).
OR, Frame Allowance: $150 toward any frame from provider plus 20% off any
balance. No copay required.
CONTACT LENSES
in lieu of eyeglasses
12 months
$0
Contact Lens Allowance: $150 allowance toward any contacts from provider’s
supply plus 15% off balance. No copay required.
OR, Medically Necessary Contacts: Covered in full with prior approval.
OPTIONAL FRAMES,
LENS TYPES AND COATINGS
Fashion
Designer
Premier
TINTING OF PLASTIC LENSES
OVERSIZE LENSES
SCRATCH-RESISTANT LENSES
ULTRAVIOLET COATING
Standard
ANTI-REFLECTIVE
Premium
COATING
Ultra
POLYCARBONATE LENSES
HIGH-INDEX LENSES
Standard
Select
PROGRESSIVE LENSES
Premium
Ultra
POLARIZED LENSES
PLASTIC PHOTOSENSITIVE LENSES
INTERMEDIATE-VISION LENSES
BLENDED SEGMENT LENSES
Single
Vision
SCRATCH PROTECTION
PLAN
Multifocal
Lenses
DAVIS VISION
COLLECTION FRAMES
MEMBER PRICE
$0
$0
$0
$0
$0
$0
$0
$35
$48
$60
$0** - $30
$0
$0
$70
$90
$190
$75
$0
$30
$20
To find participating providers, please visit
davisvision.com or call 1.877.923.2847 and
enter client code 3165.
Please note: Your provider reserves the right to not dispense
materials until all applicable member costs, fees and
copayments have been collected. Contact lenses: Routine
eye examinations do not include professional services for
contact lens evaluations. Any applicable fees above the
evaluation and fitting allowance are the responsibility of the
member. If contact lenses are selected and fitted, they may
not be exchanged for eyeglasses. Progressive lenses: If you
areunable to adapt to progressive addition lenses you have
purchased, conventional bifocals will be supplied at no
additional cost; however, your copayment is nonrefundable.
May not be combined with other discounts or offers. Please
be advised these lens options and copayments apply to
in-network benefits.
$20
$40
* The Davis Vision Collection is available at most participating
independent provider locations.
**For dependent children, monoclar patients and patients
with prescriptions of +/- 6.00 diopters or greater.
00186 1115
570 Broad Street, Suite 1100, Newark, NJ 07102 | Tel: 888 990 5706 | newjersey.healthrepublic.us
Coverage underwritten by HM Life Insurance Company