NONGROUP ENROLLMENT/CHANGE REQUEST
Health Republic Insurance of New Jersey
Enrollment of a new Enrollee
Add Spouse/Civil Union Partner
Add Domestic Partner
Add Dependent Child
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Remove Subscriber
Remove Spouse/Civil Union Partner
Remove Domestic Partner
Remove Dependent Child
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
_______________________________________________
OTHER
CHANGE
ADD
Reason
REMOVE
A. Type of Activity – to be completed by Subscriber. Refer to instructions on page 5 before completing this form. Print clearly.
Activity – Check all that apply
Date of Event
Name Change
Change Plan
Special Enrollment Period (due to a Triggering Event*)
Other
*See list of Triggering Events in Instructions
Name (Last, First, MI):
B. Subscriber Information
SSN:
Birthdate (mm/dd/yyyy)
Address Information
Are you a resident of New Jersey?
Yes
No
Male
Female
Email:
By providing an email address you consent to receive information, including
the policy, by electronic means.
Do you maintain a home in any other state or country?
Yes
No If yes:
Name of State/Country:________________________ Number of months you live there each year: _________
Primary Residence:
Street/Apt:___________________________________________________________
Street/Apt:___________________________________________________________
City:___________________________________________________ State:______
Zip Code: _____________________
Phone: (_____)_________________
Your billing address:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Primary residence
NJ-HINT-Individual 01/2016
Other residence
Other Residence:
Street/Apt:___________________________________________________________
Street/Apt:___________________________________________________________
City:___________________________________________________ State:______
Zip Code: _____________________
Phone: (_____)_________________
P.O. Box or Other (specify):
1
HRINJ © 2016
Are you eligible for Medicare?
Yes
No
Are you covered under any health coverage?
Yes
Are you covered under Medicare Parts A or B?
Yes
No
If yes, why are you applying for individual coverage?
Please note: If you are eligible for Medicare, the individual policy will coordinate as
________________________________
secondary payor to what Medicare paid or would have paid. Individual policies do not
operate as Medicare supplement policies.
C. Plan Option – Check one Plan Name and Information regarding pediatric dental coverage
Health Republic Full Access Prime:
Health Republic Full Access Pure:
Bronze
Bronze
Silver
Silver
No
Health Republic Active Access Spotlight
Plan:
Bronze
Silver
Health Republic Full Access Solid:
Gold
Platinum
Bronze (HSA)
Silver (HSA)
Gold
Health Republic Full Access Core:
Silver
Gold
Platinum
Health Republic CentraState Community Plan:
Bronze
Health Republic Vital:
Catastrophic*
*available to individuals under 30 or individuals who
received a certificate of exemption from the marketplace
only
Platinum
NJ-HINT-Individual 01/2016
2
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.
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.
HRINJ © 2016
D. Other Individuals Covered – Identify individuals other than yourself for whom you are adding/changing/removing coverage. Attach additional pages if necessary, dated and
signed by you..
1. Spouse/Domestic Partner/Civil
2. Child
3. Child
4. Child
Union Partner
Add
Remove
Other
Add
Remove
Other
Add
Remove Other
Add
Remove Other
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):
Male
Female
Male
Social Security Number:
Eligible for Medicare?
Female
Male
Social Security Number:
Yes
No
Covered under any health coverage?
Yes
No
Eligible for Medicare?
Female
Male
Social Security Number:
Yes
No
Eligible for Medicare?
Covered under any health coverage?
Yes
No
Social Security Number:
Yes
No
Covered under any health coverage?
Yes
No
If last name is different from Subscriber’s,
If last name is different from Subscriber’s,
please explain:
please explain:
___________________________
___________________________
___________________________
___________________________
Home address same as Subscriber?
Home address same as Subscriber?
Home address same as Subscriber?
Yes
No
Yes
No
Yes
No
If NO, complete Section E
If NO, complete Section F
If NO, complete Section F
E. Additional Spouse/Domestic Partner/Civil Union Partner Information – If not applicable, please mark as “NA.”
If last name is different from Subscriber’s,
please explain:
___________________________
a. Street/Apt:______________________________________________________________________________________
Street/Apt:______________________________________________________________________________________
City, State, Zip Code:
NJ-HINT-Individual 01/2016
3
Female
Eligible for Medicare?
Yes
No
Covered under any health coverage?
Yes
No
If last name is different from
Subscriber’s, please explain:
___________________________
___________________________
Home address same as Subscriber?
Yes
No
If NO, complete Section F
b. Please explain why the address is different:
_____________________________________________
_____________________________________________
HRINJ © 2016
F. Additional Child Information – Provide information below about children listed in Section D, if they have a different address. 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 – Response is
appreciated but NOT required!
H.
Payment Information –
indicate how you would like to
make payment
American Indian or Alaskan Native
Asian or Pacific Islander
I. Subscriber’s Signature
J. Broker/General Agent
Signature
Choose a category that most closely describes you:
Black, not of Hispanic origin
White, not of Hispanic origin
Hispanic
Check
Money Order
Automatic Bank Draft (attach voided check and complete attached Monthly ACH Authorization form)
For credit card payment, please visit newjersey.healthrepublic.us/make-a-payment or call 888.990.5706.
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
Enrollment/Change Request form
Signature:
Signature of Preparer
Date:
NJ Producer License #
Date
/
General Agent
NJ-HINT-Individual 01/2016
/
Agent ID #
4
HRINJ © 2016
INSTRUCTIONS AND ELIGIBILITY REQUIREMENTS
Instructions
Eligibility
 Except for section G, you must complete sections A through I, and sign and date this A. Eligibility requirements are set forth under the Individual Health Coverage Reform
form, as well as any additional pages you may need to submit with it to provide
Act of 1992, P.L. 1992, c. 161 (N.J.S.A. 17B:27A-2 et seq.).
further requested information.
B. You MUST be a New Jersey resident which means your primary residence is in New
 Please PRINT except when a signature is requested.
Jersey
 If a dependent child is disabled and you want to continue his or her coverage beyond C. You must not be enrolled for Medicare Parts A or B.
age 26, describe this in “Other Change” in Section A, and attach proof of disability.
D. If application is made for the Catastrophic Plan the following additional
 If you are applying to add a spouse, civil union partner, domestic partner, or child
requirements apply:
please check the applicable box in the “Add” section in A and identify the applicable
1. You must be under 30 years old; OR
triggering event in the reason section “Other Change” section in A.
2. You must have a Certificate of Exemption from the Marketplace. Attach a
 Eligible for Medicare means the person satisfies the requirements for Medicare but
copy to your application.
has not yet enrolled for Medicare. Covered under Medicare Parts A or B mean you
The Annual Open Enrollment Period is the designated period of time each year
have Medicare and CANNOT enroll for an individual plan.
during which you may apply for or change coverage for yourself and family
 You can obtain the providers’ correct names and addresses from the appropriate
members who are currently uninsured or who are covered under another individual
provider directory. You may also obtain each provider’s NPI number from our
plan, or who are covered under a group health plan, group health benefits plan, a
online provider directory at newjersey.healthrepublic.us/providersearch or by
governmental plan, a church plan. Your application must be received during the
contacting the provider directly. Providers with multiple office locations and
Annual Open Enrollment Period. The effective date of coverage applied for by
individual providers who belong to more than one practice or provider entity may
December 31 will be January 1. If the designated Annual Open Enrollment Period
have more than one NPI number. You should confirm the correct NPI number for
extends beyond December, the effective date of coverage will be the first of the
the specific provider and office location where you will be seen by contacting that
month following the date of the application.
office directly.
A Special Enrollment Period that lasts for 60 days follows the Triggering Events
 For provider addresses, include the zip code plus the four digit extension (11 digits)
listed above. The effective date of a new policy will be no later than the first of the
 IF YOU HAVE ANY QUESTIONS concerning the benefits and services provided
month following receipt of the application. In addition if the Triggering Event is the
by or excluded under this policy, contact a member services representative at 1-888loss of eligibility for minimum essential coverage, the Special Enrollment Period
990-5706 before signing this form.
includes the 60 days prior to the Triggering Event.
 KEEP A COPY OF THIS COMPLETED APPLICATION! A copy of this
NOTE: If you currently have coverage the plan for which you are applying must
application may be used as a temporary ID card for 30 days from the effective date if
REPLACE the current coverage but you SHOULD NOT terminate it until the new
authorized by Health Republic Insurance of New Jersey. Coverage must be verified
coverage is effective.
with Health Republic Insurance of New Jersey prior to visiting with a specialist or
admission to a hospital. For a temporary ID card, please contact Member Services at
Eligibility for a vision plan is based on the active status of your individual health
1-888-990-5706.
policy.
 Triggering Events:
1. loss of eligibility for minimum essential coverage but not if lost due to nonpayment of premium
2. dependent attained age 26 or 31 and lost coverage
3. Marketplace changed your subsidy determination
4. New dependent due to marriage, birth, adoption or placement for adoption,
placement in foster care
5. gained access to New Jersey plans as a result of permanent move to New Jersey
6. child support order or other order requiring coverage
Please note: You must provide evidence of the triggering event with your
enrollment form.
NJ-HINT-Individual 01/2016
5
HRINJ © 2016
CONDITIONS OF ENROLLMENT -- SUBSCRIBER 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 individual policy.
5. I understand that my enrollment and the enrollment of my listed dependents in Health Republic Insurance of New Jersey’s individual policy is subject to acceptance by
Health Republic Insurance of New Jersey.
6. 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 individual policy if
premiums are not paid timely.
MISREPRESENTATIONS
Any person who includes any false or misleading information on a Nongroup Enrollment/Change Request Form for a health benefits plan is subject to criminal and civil penalties.
NJ-HINT-Individual 01/2016
6
HRINJ © 2016
2016 Individual Rates
Full Access Core, Full Access Prime,
Full Access Solid and Vital
Full Access Core Plans
Full Access Solid Plans
Full Access Prime Plans
Vital Plans
Age
0-20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65+
SILVER
GOLD
PLATINUM
BRONZE
SILVER
BRONZE
SILVER
GOLD
CATASTROPHIC
$196.41
$309.30
$309.30
$309.30
$309.30
$310.54
$316.72
$324.15
$336.21
$346.11
$351.06
$358.48
$365.90
$370.54
$375.49
$377.96
$380.44
$382.91
$385.39
$390.34
$395.29
$402.71
$409.82
$419.72
$432.09
$446.63
$463.95
$483.44
$505.71
$527.67
$552.41
$576.84
$603.75
$630.97
$660.36
$689.74
$721.60
$753.76
$788.10
$805.11
$839.44
$869.13
$888.62
$913.05
$927.90
$927.90
$264.56
$416.63
$416.63
$416.63
$416.63
$418.30
$426.63
$436.63
$452.88
$466.21
$472.88
$482.87
$492.87
$499.12
$505.79
$509.12
$512.45
$515.79
$519.12
$525.79
$532.45
$542.45
$552.03
$565.37
$582.03
$601.61
$624.95
$651.19
$681.19
$710.77
$744.10
$777.01
$813.26
$849.93
$889.51
$929.08
$972.00
$1,015.33
$1,061.57
$1,084.49
$1,130.73
$1,170.73
$1,196.98
$1,229.89
$1,249.89
$1,249.89
$323.66
$509.70
$509.70
$509.70
$509.70
$511.74
$521.93
$534.17
$554.04
$570.35
$578.51
$590.74
$602.98
$610.62
$618.78
$622.85
$626.93
$631.01
$635.09
$643.24
$651.40
$663.63
$675.35
$691.66
$712.05
$736.01
$764.55
$796.66
$833.36
$869.55
$910.32
$950.59
$994.93
$1,039.79
$1,088.21
$1,136.63
$1,189.13
$1,242.14
$1,298.72
$1,326.75
$1,383.33
$1,432.26
$1,464.37
$1,504.63
$1,529.10
$1,529.10
$188.06
$296.16
$296.16
$296.16
$296.16
$297.34
$303.27
$310.38
$321.93
$331.40
$336.14
$343.25
$350.36
$354.80
$359.54
$361.91
$364.28
$366.65
$369.02
$373.75
$378.49
$385.60
$392.41
$401.89
$413.74
$427.66
$444.24
$462.90
$484.22
$505.25
$528.94
$552.34
$578.10
$604.17
$632.30
$660.44
$690.94
$721.74
$754.62
$770.90
$803.78
$832.21
$850.87
$874.26
$888.48
$888.48
$192.57
$303.26
$303.26
$303.26
$303.26
$304.47
$310.54
$317.82
$329.64
$339.35
$344.20
$351.48
$358.76
$363.31
$368.16
$370.58
$373.01
$375.44
$377.86
$382.71
$387.57
$394.84
$401.82
$411.52
$423.65
$437.91
$454.89
$474.00
$495.83
$517.36
$541.62
$565.58
$591.96
$618.65
$647.46
$676.27
$707.51
$739.04
$772.71
$789.39
$823.05
$852.16
$871.27
$895.22
$909.78
$909.78
$188.07
$296.17
$296.17
$296.17
$296.17
$297.35
$303.28
$310.39
$321.94
$331.41
$336.15
$343.26
$350.37
$354.81
$359.55
$361.92
$364.29
$366.66
$369.03
$373.77
$378.51
$385.61
$392.43
$401.90
$413.75
$427.67
$444.26
$462.91
$484.24
$505.27
$528.96
$552.36
$578.12
$604.19
$632.32
$660.46
$690.96
$721.77
$754.64
$770.93
$803.81
$832.24
$850.90
$874.29
$888.51
$888.51
$192.56
$303.25
$303.25
$303.25
$303.25
$304.46
$310.53
$317.81
$329.63
$339.34
$344.19
$351.47
$358.74
$363.29
$368.15
$370.57
$373.00
$375.42
$377.85
$382.70
$387.55
$394.83
$401.81
$411.51
$423.64
$437.89
$454.88
$473.98
$495.81
$517.34
$541.60
$565.56
$591.94
$618.63
$647.44
$676.25
$707.48
$739.02
$772.68
$789.36
$823.02
$852.13
$871.24
$895.19
$909.75
$909.75
$270.91
$426.63
$426.63
$426.63
$426.63
$428.34
$436.87
$447.11
$463.75
$477.40
$484.23
$494.46
$504.70
$511.10
$517.93
$521.34
$524.75
$528.17
$531.58
$538.41
$545.23
$555.47
$565.28
$578.94
$596.00
$616.05
$639.95
$666.82
$697.54
$727.83
$761.96
$795.66
$832.78
$870.33
$910.86
$951.38
$995.33
$1,039.70
$1,087.05
$1,110.52
$1,157.87
$1,198.83
$1,225.71
$1,259.41
$1,279.89
$1,279.89
$148.69
$234.15
$234.15
$234.15
$234.15
$235.09
$239.77
$245.39
$254.52
$262.01
$265.76
$271.38
$277.00
$280.51
$284.26
$286.13
$288.00
$289.88
$291.75
$295.50
$299.24
$304.86
$310.25
$317.74
$327.11
$338.11
$351.23
$365.98
$382.84
$399.46
$418.19
$436.69
$457.06
$477.67
$499.91
$522.15
$546.27
$570.62
$596.61
$609.49
$635.48
$657.96
$672.71
$691.21
$702.45
$702.45
570 Broad Street, Suite 1100, Newark, NJ 07102 | Tel: 888 990 5706 | newjersey.healthrepublic.us
00097 1115
2016 Individual Rates
Full Access Pure, Active Access Spotlight and
CentraState Community
CentraState
Community Plan
Active Access Spotlight Plans
Full Access Pure Plans
Age
0-20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65+
BRONZE
SILVER
GOLD
PLATINUM
BRONZE
SILVER
PLATINUM
BRONZE
$179.50
$282.67
$282.67
$282.67
$282.67
$283.80
$289.45
$296.24
$307.26
$316.31
$320.83
$327.61
$334.40
$338.64
$343.16
$345.42
$347.68
$349.95
$352.21
$356.73
$361.25
$368.04
$374.54
$383.58
$394.89
$408.18
$424.01
$441.81
$462.17
$482.24
$504.85
$527.18
$551.77
$576.65
$603.50
$630.35
$659.47
$688.87
$720.24
$735.79
$767.17
$794.30
$812.11
$834.44
$848.01
$848.01
$192.01
$302.38
$302.38
$302.38
$302.38
$303.59
$309.64
$316.89
$328.69
$338.36
$343.20
$350.46
$357.72
$362.25
$367.09
$369.51
$371.93
$374.35
$376.77
$381.60
$386.44
$393.70
$400.65
$410.33
$422.42
$436.64
$453.57
$472.62
$494.39
$515.86
$540.05
$563.94
$590.25
$616.86
$645.58
$674.31
$705.45
$736.90
$770.46
$787.10
$820.66
$849.69
$868.74
$892.63
$907.14
$907.14
$270.54
$426.05
$426.05
$426.05
$426.05
$427.75
$436.28
$446.50
$463.12
$476.75
$483.57
$493.79
$504.02
$510.41
$517.22
$520.63
$524.04
$527.45
$530.86
$537.68
$544.49
$554.72
$564.52
$578.15
$595.19
$615.22
$639.08
$665.92
$696.59
$726.84
$760.93
$794.58
$831.65
$869.14
$909.62
$950.09
$993.97
$1,038.28
$1,085.58
$1,109.01
$1,156.30
$1,197.20
$1,224.04
$1,257.70
$1,278.15
$1,278.15
$334.21
$526.32
$526.32
$526.32
$526.32
$528.43
$538.95
$551.58
$572.11
$588.95
$597.37
$610.00
$622.64
$630.53
$638.95
$643.16
$647.37
$651.58
$655.79
$664.22
$672.64
$685.27
$697.37
$714.22
$735.27
$760.01
$789.48
$822.64
$860.53
$897.90
$940.01
$981.59
$1,027.38
$1,073.69
$1,123.69
$1,173.69
$1,227.90
$1,282.64
$1,341.06
$1,370.01
$1,428.43
$1,478.96
$1,512.12
$1,553.70
$1,578.96
$1,578.96
$172.33
$271.39
$271.39
$271.39
$271.39
$272.48
$277.90
$284.42
$295.00
$303.69
$308.03
$314.54
$321.05
$325.13
$329.47
$331.64
$333.81
$335.98
$338.15
$342.49
$346.84
$353.35
$359.59
$368.28
$379.13
$391.89
$407.09
$424.18
$443.72
$462.99
$484.70
$506.14
$529.75
$553.64
$579.42
$605.20
$633.15
$661.38
$691.50
$706.43
$736.55
$762.61
$779.70
$801.14
$814.17
$814.17
$184.49
$290.53
$290.53
$290.53
$290.53
$291.69
$297.50
$304.48
$315.81
$325.10
$329.75
$336.72
$343.70
$348.05
$352.70
$355.03
$357.35
$359.68
$362.00
$366.65
$371.30
$378.27
$384.95
$394.25
$405.87
$419.53
$435.80
$454.10
$475.02
$495.64
$518.89
$541.84
$567.11
$592.68
$620.28
$647.88
$677.81
$708.02
$740.27
$756.25
$788.50
$816.39
$834.69
$857.64
$871.59
$871.59
$319.23
$502.72
$502.72
$502.72
$502.72
$504.73
$514.79
$526.85
$546.46
$562.54
$570.59
$582.65
$594.72
$602.26
$610.30
$614.32
$618.35
$622.37
$626.39
$634.43
$642.48
$654.54
$666.10
$682.19
$702.30
$725.93
$754.08
$785.75
$821.95
$857.64
$897.86
$937.57
$981.31
$1,025.55
$1,073.31
$1,121.07
$1,172.85
$1,225.13
$1,280.93
$1,308.58
$1,364.38
$1,412.64
$1,444.31
$1,484.03
$1,508.16
$1,508.16
$159.18
$250.68
$250.68
$250.68
$250.68
$251.68
$256.70
$262.71
$272.49
$280.51
$284.52
$290.54
$296.55
$300.31
$304.33
$306.33
$308.34
$310.34
$312.35
$316.36
$320.37
$326.39
$332.15
$340.17
$350.20
$361.98
$376.02
$391.81
$409.86
$427.66
$447.71
$467.52
$489.33
$511.39
$535.20
$559.02
$584.84
$610.91
$638.73
$652.52
$680.35
$704.41
$720.20
$740.01
$752.04
$752.04
570 Broad Street, Suite 1100, Newark, NJ 07102 | Tel: 888 990 5706 | newjersey.healthrepublic.us
Residency Requirements:
Please be aware that
Active Access Spotlight Plans
are not available to residents
of Salem County.
Additionally, the CentraState
Community Plan is available
to residents throughout
Monmouth County, as well
as to those living in select
areas of Mercer, Middlesex,
and Ocean counties.
00098 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
Individual
BRONZE
SILVER
GOLD
$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 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 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 INDIVIDUALS
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 = $11.00
Member + 1 = $19.80
Member + Family = $30.80
00184 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
Monthly ACH Authorization Form
To make bill paying a little easier, you can elect to have your monthly health plan premium and any outstanding
past due balances or fees automatically deducted from your bank account each month. By completing this
document, you are authorizing Health Republic Insurance of New Jersey to debit the dollar amount showing on the
current Health Republic Insurance of New Jersey premium invoice from the bank account indicated below on the
1st of each month according to the terms of the premium billing. Once complete, please see reverse for address to
mail this form.
_________________________
Last Name
____________________
First Name
__________________
Member ID Number
_________________________
Business Name
____________________
Group ID Number
______________________________
Employee Authorized for Account
I hereby authorize Health Republic Insurance of New Jersey to withdraw the dollar amount showing on the current
Health Republic Insurance of New Jersey premium invoice by initiating debit entries to my account on the 1st of each
month at the Financial Institution (herein after BANK) indicated below. Further, I authorize BANK to accept and to
charge any debit entries initiated by Health Republic Insurance of New Jersey to my account. In the event that Health
Republic Insurance of New Jersey withdraws funds erroneously from my account, I authorize Health Republic
Insurance of New Jersey to credit my account for an amount not to exceed the original amount of the debit.
I WANT TO: (CHOOSE ONE)
Authorize monthly debits
Type of Account:
Update bank account information
Checking Account
Cancel monthly debits on
/
/
Savings Account
Bank Name:
Bank Routing/Transit Number: _________________________________
Bank Account Number: _________________________________
See reverse for assistance finding Routing/Transit/Account Numbers on your check.
Please include a voided check when you return this form to us.
This authorization is to remain in full force and effect until Health Republic Insurance of New Jersey and/or BANK
has received written notice from me of its termination in such time and in such manner as to afford Health Republic
Insurance of New Jersey and/or BANK a reasonable opportunity to act on it. This automatic monthly debit will stop
if I change accounts that would affect this withdrawal, or if any changes are made to my account which may affect
my monthly payment amount. I am aware that I must complete another Monthly ACH Authorization Form to
continue automatic monthly debits. If there is a lapse in payment due to a change in this account, it is my
responsibility to ensure that another method of payment is provided during any lapse due to changes in this account.
Signature X
Date
/
/
Automatic monthly debits will be taken from your account starting with the first invoice issued after we receive the
completed form from you.
00095 1015
*Your Bank Routing / Transit Number / Account Number may be found on your check:
Call us. We’re here to answer your questions.
If you have any questions about this form, please contact the Health Republic Member Services Team at
888.990.5706. The Health Republic Member Services Team is available Monday through Friday (except for
national holidays), 8:30 am – 5:30 pm ET.
Please mail this completed form and a voided check to:
Health Republic Insurance of New Jersey
P.O. Box 467965
Atlanta, GA 31146
00095 1015