Other Coverage Information Sample Clauses

Other Coverage Information. Type of Coverage COBRA Group/Employer Individual Other Will your current health care coverage be terminated upon acceptance or enrollment with ▇▇▇▇▇▇ Health Plus? Yes No Primary Policy Holder Name(s) (Last, First, MI) Insurance Carrier Name All Dependents’ Names and Other Health Plan ID Numbers Policy Number The broker of record may receive monetary payments from ▇▇▇▇▇▇ Health Plus in connection with the purchase of this coverage. Premiums are the same whether or not you use an agent, broker, or other representative. ▇▇▇▇▇, ▇▇▇▇▇▇, or Representative Name ▇▇▇▇▇ ▇▇▇▇▇▇▇▇ Section H1 – To be completed by your agent, broker, or representative after completion of this application. If you have assisted the applicant in submitting the application, the law requires that you attest to this assistance. If, in making this attestation, you state as true any material fact you know to be false, you will be subject to a civil penalty of up to ten thousand dollars ($10,000), as authorized under California Health and Safety Code section 1389.8I or Insurance Code section 10119.3, in addition to any other applicable penalties or remedies available under current law. I assisted the applicant in submitting this application. To the best of my knowledge, the information on this application is complete and accurate. I explained to the applicant, in easy-to-understand language, the risk to the applicant of providing inaccurate information, and the applicant understood the explanation. Agent, Broker or Representative Signature Date Calabasas Ca 91302 Phone Fax Email Address ▇▇▇-▇▇▇-▇▇▇▇ ▇▇▇-▇▇▇-▇▇▇▇ ▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇.▇▇▇ Agency Name License Number SHP ID Number 954864046 Section H1 – To be completed by your agent, broker, or representative after completion of this application. ‌‌‌‌ Last Name First Name MI ▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇▇ Street Address ▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇ City County State ZIP Section I – Member Agreement (Please read the following information carefully). I declare that I have read this application, the answers provided, and the documents enclosed. I have had an opportunity to review the Individual and Family Plan Membership Agreement and EOC (Agreement) and by signing this document accept all terms and rates and conditions set forth in the Agreement. I certify that the information provided with this application is true, complete, and correct to the best of my knowledge. If this application is accepted by the health plan, then my signature will result in a b...

Other Coverage Information. If your spouse is also a PASSHE employee or annuitant eligible to participate in either the active coverage or the Annuitant Health Care Program (AHCP), he or she may enroll as a single subscriber under his/her own plan, or as a dependent under the active employee’s coverage, but not both. Likewise, dependents may only be covered under one PASSHE active group plan or PASSHE-AHCP plan. If your spouse is covered under the Pennsylvania Employees Benefit Trust Fund (PEBTF), the employee and dependents may be enrolled on each other’s policies for the purpose of coordination of benefits. Spouses eligible for fully-paid employer coverage through his/her employer must be enrolled in their employer’s coverage and State System health coverage will provide minimal benefits as secondary payer only. (This only applies to spouses added to health coverage after July 1, 2001.)