ࡱ> #` Nbjbj\.\. >>D>D}[*******>fff8t>r: "BBB HJJJJJJ$;hvn*n**BBp*B*BHH8**$B. p/rW}f"pT"l 0v"D$*$H^L)nn^>>>ZB_$X>>>B_>>>****** NONGROUP ENROLLMENT/CHANGE REQUEST [Carrier Logo] [Carrier Name] A. Type of Activity to be completed by [Applicant] Refer to instructions [on back] before completing this form. Print clearly. Activity Check all that applyEffective Date/ Date of EventReasonADD FORMCHECKBOX  Enrollment of a new [Insured/Enrollee/Subscriber]  FORMCHECKBOX  Add Spouse[/Civil Union Partner] [ FORMCHECKBOX  Add Civil Union Partner]  FORMCHECKBOX  Add Domestic Partner  FORMCHECKBOX  Add Dependent Child_____/_____/_____ _____/_____/_____ [_____/_____/_____] _____/_____/_____ _____/_____/_____________________________________________________________ ________________________________________________________ [_______________________________________________________] ________________________________________________________ ________________________________________________________ REMOVE FORMCHECKBOX  Remove [Insured/Enrollee/Subscriber]  FORMCHECKBOX  Remove Spouse[/Civil Union Partner] [ FORMCHECKBOX  Remove Civil Union Partner]  FORMCHECKBOX  Remove Domestic Partner  FORMCHECKBOX  Remove Dependent Child_____/_____/_____ _____/_____/_____ [_____/_____/____] _____/_____/_____ _____/_____/_____________________________________________________________ ________________________________________________________ [_______________________________________________________] ________________________________________________________ ________________________________________________________ OTHER CHANGE FORMCHECKBOX  Name Change  FORMCHECKBOX  Change Plan  FORMCHECKBOX  Other  FORMCHECKBOX  [Add/Change Office ID Numbers: Primary/OB/Gyn] _____/_____/_____ _____/_____/_____ _____/_____/_____ _____/_____/_____ _______________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________B. [Applicant] Information Name (Last, First, MI): SSN:Birthdate (mm/dd/yyyy) FORMCHECKBOX  Male  FORMCHECKBOX  Female[Email:]Are you a resident of New Jersey?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoDo you maintain a home in any other state?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Name of State:______________________________ Number of months you live there each year: _________Address InformationPrimary Residence: Street/Apt:___________________________________________________________ Street/Apt:___________________________________________________________ City:___________________________________________________ State:______ Zip Code: _____________________ Phone: (_____)_________________Other Residence: Street/Apt:___________________________________________________________ Street/Apt:___________________________________________________________ City:___________________________________________________ State:______ Zip Code: _____________________ Phone: (_____)_________________Your billing address:  FORMCHECKBOX  Primary residence  FORMCHECKBOX  Other residence  FORMCHECKBOX  P.O. Box or Other (specify):Activity FORMCHECKBOX  Add  FORMCHECKBOX  Remove  FORMCHECKBOX  Other Change  FORMCHECKBOX  Continue If a name change, indicate prior name:[Primary ______________________________________________________________ address: zip+4 ][NPI #:][Current Patient:  FORMCHECKBOX  Yes  FORMCHECKBOX  No][Ob/Gyn ______________________________________________________________ address:] zip+4 [NPI #:][Current Patient:  FORMCHECKBOX  Yes  FORMCHECKBOX  No] Are you covered under Other Health Coverage?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Payer Name: ____________________________________________________________ Policy #: ___________________________________________ Medicare ID#, if any: Why are you applying for individual coverage? ________________________________ Are you eligible but not covered under Other Health Coverage?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, what is it?  FORMCHECKBOX  Group plan via employment (specify payer): _______________________________  FORMCHECKBOX  Medicaid/NJFamilyCare  FORMCHECKBOX  Medicare  FORMCHECKBOX  Other (specify): ___________________________ Previous Coverage?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes: Effective date: _____/_____/_____ Termination date: _____/_____/_____ Payer Name:____________________________________________________ Policy #:____________________________ [Submit a Certificate of Creditable Coverage]What was it?  FORMCHECKBOX  Individual  FORMCHECKBOX  Group  FORMCHECKBOX  Medicaid/NJFamilyCare  FORMCHECKBOX  Other (specify): What Plan Type?  FORMCHECKBOX  Indemnity  FORMCHECKBOX  PPO  FORMCHECKBOX  POS  FORMCHECKBOX  HMO  FORMCHECKBOX  OtherCost-sharing requirements: Deductible amount: $______________ Coinsurance amount: _________% Copayment amount: $_____________Did coverage terminate as a result of fraud or failure to pay premiums? Were you allowed to make a COBRA continuation election, or a continuation election under State law, if any, when coverage ended? If Yes, did you elect to continue and remain covered for the entire continuation period available to you? Were you covered for 18 months or more under any previous plan(s)? Have you experienced more than a 63-day break in coverage between any previous plan, including your most recent plan and the date of this application?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  NoC. Plan Option Check one [Plan Name] [and] [Copay] [and] [or] [Deductible] [and] [or] [Coverage Status] 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.. [Attach proof if full-time post-secondary student.] [Attach proof of disability.] 1. Spouse/Domestic Partner/Civil Union Partner2. Child3. Child4. Child FORMCHECKBOX  Add  FORMCHECKBOX  Remove  FORMCHECKBOX  Other  FORMCHECKBOX  Add  FORMCHECKBOX  Remove  FORMCHECKBOX  Other  FORMCHECKBOX  Add  FORMCHECKBOX  Remove  FORMCHECKBOX Other  FORMCHECKBOX  Add  FORMCHECKBOX  Remove  FORMCHECKBOX Other Name (last, first, MI) L:________________________________ F:________________________________ MI:Name (last, first, MI) L:_________________________________ F:_________________________________ MI:Name (last, first, MI) L:_________________________________ F:_________________________________ MI:Name (last, first, MI) L:_______________________________ F:_________________________________ MI:Birthdate (mm/dd/yyyy): Birthdate (mm/dd/yyyy): Birthdate (mm/dd/yyyy): Birthdate (mm/dd/yyyy):  FORMCHECKBOX  Male  FORMCHECKBOX  Female FORMCHECKBOX  Male  FORMCHECKBOX  Female FORMCHECKBOX  Male  FORMCHECKBOX  Female FORMCHECKBOX  Male  FORMCHECKBOX  FemaleSocial Security Number: Social Security Number: Social Security Number: Social Security Number: Previous Coverage?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Effective:____/____/___ Termination: ___/___/___ Payer:____________________________ Policy #: __________________ What was it?  FORMCHECKBOX  Individual  FORMCHECKBOX  Group  FORMCHECKBOX  Medicaid/NJFamilyCare  FORMCHECKBOX  Other (specify): __________________________________ What Plan type?  FORMCHECKBOX  Indemnity  FORMCHECKBOX  PPO  FORMCHECKBOX  POS  FORMCHECKBOX  HMO  FORMCHECKBOX  None of the above Cost-sharing requirements: Deductible: $______________ Coinsurance: _________% Copayment: $_____________ Why did coverage end? ________________________________ Was continuation upon termination an option?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, was continuation elected and coverage retained for full continuation period?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Does total previous coverage equal 18 months or more?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Any breaks in coverage of more than 63 days?  FORMCHECKBOX  Yes  FORMCHECKBOX  N [submit a copy of the Certificate of Creditable Coverage] Previous Coverage?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Effective:____/____/___ Termination: ___/___/___ Payer :____________________________ Policy #: ____________________ What was it?  FORMCHECKBOX  Individual  FORMCHECKBOX  Group  FORMCHECKBOX  Medicaid/NJFamilyCare  FORMCHECKBOX  Other (specify): __________________________________ What Plan type?  FORMCHECKBOX  Indemnity  FORMCHECKBOX  PPO  FORMCHECKBOX  POS  FORMCHECKBOX  HMO  FORMCHECKBOX  None of the above Cost-sharing requirements: Deductible: $______________ Coinsurance: _________% Copayment: $_____________ Why did coverage end? __________________________________ Was continuation upon termination an option?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, was continuation elected and coverage retained for full continuation period?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Does total previous coverage equal 18 months or more?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Any breaks in coverage of more than 63 days?  FORMCHECKBOX  Yes  FORMCHECKBOX  N [submit a copy of the Certificate of Creditable Coverage] Previous Coverage?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Effective:____/____/___ Termination: ___/___/___ Payer:_____________________________ Policy #: __________________ What was it?  FORMCHECKBOX  Individual  FORMCHECKBOX  Group  FORMCHECKBOX  Medicaid/NJFamilyCare  FORMCHECKBOX  Other (specify): __________________________________ What Plan type?  FORMCHECKBOX  Indemnity  FORMCHECKBOX  PPO  FORMCHECKBOX  POS  FORMCHECKBOX  HMO  FORMCHECKBOX  None of the above Cost-sharing requirements: Deductible: $______________ Coinsurance: _________% Copayment: $_____________ Why did coverage end? __________________________________ Was continuation upon termination an option?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, was continuation elected and coverage retained for full continuation period?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Does total previous coverage equal 18 months or more?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Any breaks in coverage of more than 63 days?  FORMCHECKBOX  Yes  FORMCHECKBOX  N [submit a copy of the Certificate of Creditable Coverage] Previous Coverage?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Effective:____/____/___ Termination: ___/___/___ Payer:____________________________ Policy #: ___________________ What was it?  FORMCHECKBOX  Individual  FORMCHECKBOX  Group  FORMCHECKBOX  Medicaid/NJFamilyCare  FORMCHECKBOX  Other (specify): _________________________________ What Plan type?  FORMCHECKBOX  Indemnity  FORMCHECKBOX  PPO  FORMCHECKBOX  POS  FORMCHECKBOX  HMO  FORMCHECKBOX  None of the above Cost-sharing requirements: Deductible: $______________ Coinsurance: _________% Copayment: $_____________ Why did coverage end? _________________________________ Was continuation upon termination an option?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, was continuation elected and coverage retained for full continuation period?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Does total previous coverage equal 18 months or more?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Any breaks in coverage of more than 63 days?  FORMCHECKBOX  Yes  FORMCHECKBOX  N [submit a copy of the Certificate of Creditable Coverage] Covered under Other Health Coverage Now?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Payer Name: __________________________________ Policy #: _________________ Medicare ID #:_____________ Eligible but not covered under Other Health Coverage?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes, identify the type:  FORMCHECKBOX Group Payer:__________________________  FORMCHECKBOX Medicare  FORMCHECKBOX Medicaid/NJFamilyCare  FORMCHECKBOX Other (specify) _______________________________ Covered under Other Health Coverage Now?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Payer Name: ___________________________________ Policy #: _________________ Medicare ID #:_____________ Eligible but not covered under Other Health Coverage?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes, identify the type:  FORMCHECKBOX Group Payer:___________________________  FORMCHECKBOX Medicare  FORMCHECKBOX Medicaid/NJFamilyCare  FORMCHECKBOX Other (specify) ________________________________Covered under Other Health Coverage Now?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Payer Name: ___________________________________ Policy #: _________________ Medicare ID #:_____________ Eligible but not covered under Other Health Coverage?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes, identify the type:  FORMCHECKBOX Group Payer:___________________________  FORMCHECKBOX Medicare  FORMCHECKBOX Medicaid/NJFamilyCare  FORMCHECKBOX Other (specify) ________________________________Covered under Other Health Coverage Now?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes: Payer Name: _________________________________ Policy #: _________________ Medicare ID #:_____________ Eligible but not covered under Other Health Coverage?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes, identify the type:  FORMCHECKBOX Group Payer:_________________________  FORMCHECKBOX Medicare  FORMCHECKBOX Medicaid/NJFamilyCare  FORMCHECKBOX Other (specify) ______________________________[Primary Care Provider: NPI#:____________________ Address:___________________________ __________________________________ _____________ _______ zip+4________ [Current Patient?  FORMCHECKBOX Yes  FORMCHECKBOX  No]][Primary Care Provider: NPI#:______________________ Address:____________________________ ___________________________________ __________________ zip+4___________ [Current Patient?  FORMCHECKBOX  Yes  FORMCHECKBOX  No]][Primary Care Provider: NPI#:_____________________ Address:____________________________ ___________________________________ ____________________ zip+4________ [Current Patient?  FORMCHECKBOX Yes  FORMCHECKBOX  No]][Primary Care Provider: NPI#:______________________ Address:__________________________ _________________________________ ______________ zip+4_____________ [Current Patient?  FORMCHECKBOX Yes  FORMCHECKBOX  No]][Ob/Gyn Office NPI#:_____________________ Address:___________________________ __________________________________ ___________________ zip+4_________ [Current Patient?  FORMCHECKBOX Yes  FORMCHECKBOX  No  FORMCHECKBOX  NA]][Ob/Gyn Office NPI#:____________________ Address:____________________________ ___________________________________ ___________________ zip+4 _________ [Current Patient?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  NA]][Ob/Gyn Office NPI#:______________________ Address:____________________________ ___________________________________ ___________________ zip+4 __________ [Current Patient?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  NA]][Ob/Gyn Office NPI#:______________________ Address:__________________________ _________________________________ ________________ zip+4 __________ [Current Patient?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  NA]]Employed?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, complete Section [F]1 If last name is different from [Applicants], please explain: ___________________________ ___________________________If last name is different from [Applicants], please explain: ___________________________ ___________________________If last name is different from [Applicants], please explain: ___________________________ ___________________________Home address same as [Applicant]?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If NO, complete Section [F]2Living with [Applicant]?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If NO, complete Section [G] Living with [Applicant]?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If NO, complete Section [G]Living with [Applicant]?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If NO, complete Section [G] [E. Preexisting Conditions Check all that apply. If you check one of the conditions in #1, or respond yes to any question in #2, give details on a separate sheet of paper. This separate sheet must be signed and dated by you. This information may ONLY be used to determine if a condition is a pre-existing condition. You CANNOT be denied coverage under a health benefits plan on the basis of accurate responses to the following questions. Carriers may only use the information to expedite the processing of claims.] [1. If you or any dependent to be covered has been diagnosed as having any of the following within the past 6 months, please place a check mark in the appropriate box:][2. During the past 6 months, have you or any dependent to be covered:][Yes No] [ FORMCHECKBOX  a. Alcoholism or Drug Abuse  FORMCHECKBOX  b. Arthritis  FORMCHECKBOX  c. Blood Disorder  FORMCHECKBOX  d. Back or Neck Disorder, Injury or Pain  FORMCHECKBOX  e. Cancer or Tumors  FORMCHECKBOX  f. Diabetes  FORMCHECKBOX  g. Gastro or Intestinal Disorder  FORMCHECKBOX  h. Heart Disorder/Condition /Chest Pain FORMCHECKBOX  i. High Blood Pressure  FORMCHECKBOX  j. Kidney or Liver Disorder  FORMCHECKBOX  k. Lung or Respiratory Disorder  FORMCHECKBOX  l. Mental or Nervous Disorder  FORMCHECKBOX  m. Paralysis, Stroke or Epilepsy  FORMCHECKBOX  n. Does a pregnancy exist? If so, provide expected due date: __________________________][a. been examined or treated by a physician or other health care provider for any condition, illness or injury, other than as stated above? b. been advised to have treatment or surgery or testing that has not been done? c. been admitted to a hospital or other health care facility as an inpatient? d. taken prescribed medication?][ FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX ][F.] Additional Spouse/Domestic Partner/Civil Union Partner Information If not applicable, please mark as NA.1. Employer Name:________________________________________________________________________________ Employer Address:______________________________________________________________________________ City, State, Zip Code:____________________________________________________________________________ Employer Phone: ( )2a. Street/Apt:______________________________________________________________________________________ Street/Apt:______________________________________________________________________________________ City, State, Zip Code: 2b. Please explain why the address is different: _____________________________________________ _____________________________________________ [G.] 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:________________________________________________________________[H.] Race/Ethnicity Response is appreciated but NOT required! Choose a category that most closely describes you:  FORMCHECKBOX American Indian or Alaskan Native  FORMCHECKBOX Black, not of Hispanic origin  FORMCHECKBOX Hispanic  FORMCHECKBOX Asian or Pacific Islander  FORMCHECKBOX White, not of Hispanic origin [I.] Payment Information indicate how you would like to [be billed and] make payment[ FORMCHECKBOX  Monthly  FORMCHECKBOX  Check [ FORMCHECKBOX Credit Card Type (AMEX, Visa, etc.):_____________________ [ FORMCHECKBOX  Quarterly]  FORMCHECKBOX  Money Order No.:___________________________ Exp. Date: ____/____/____ [ FORMCHECKBOX  Semi-annually]] [ FORMCHECKBOX Automatic Bank Draft (attach voided check)] Cardholder Name: [J.] [Applicants] Signature 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. I authorize deductions from my earnings for any contributions required from me. Signature: Date: [K.] Broker/General Agent SignatureSignature of PreparerDate / / NJ Producer License #General AgentAgent ID #INSTRUCTIONS AND ELIGIBILITY REQUIREMENTSInstructions Except for section [H], you must complete sections A through [J], and sign and date this form, as well as any additional pages you may need to submit with it to provide further requested information. Please PRINT except when a signature is requested. If a dependent child is disabled and you want to continue his or her coverage beyond [age 18][the limiting age], describe this in Other Change in Section A, and attach proof of disability. [If a dependent is a full-time post-secondary student, you must attach a current course schedule or a letter from the school or its authorized representative confirming full-time student status.] You can obtain the providers correct names and addresses from the appropriate provider directory. You may also obtain each providers NPI number [from the provider directory] [or] [and] [at: URL] [or] [and] [by contacting the provider directly.] Providers with multiple office locations and individual providers who belong to more than one practice or provider entity 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. For provider addresses, include the zip code plus the four digit extension (11 digits) Previous Coverage and Other Health Coverage includes coverage under a: group health plan resulting from employment, whether with a private or public (governmental) employer, including such coverage continued through a COBRA election or state continuation provisions; a church plan, Medicare, Medicaid, NJFamilyCare, or another individual health benefits plan. IF YOU HAVE ANY QUESTIONS concerning the benefits and services provided by or excluded under this [policy], contact a [member services] representative at [phone number] before signing this form. KEEP A COPY OF THIS COMPLETED APPLICATION! [A copy of this application may be used as a temporary ID card for 30 days from the effective date if authorized by [Carrier Name]. Coverage must be verified with [Carrier Name] prior to visiting with a specialist or admission to a hospital.]Eligibility Eligibility requirements are set forth under the Individual Health Coverage Reform Act of 1992, P.L. 1992, c. 161 (N.J.S.A. 17B:27A-2 et seq.). You MUST be a New Jersey resident. EXCEPT as F. below applies, you and family members you wish to cover MUST NOT be eligible to be covered under a: group health plan; a group health benefits plan; a governmental plan (not including Medicaid); a church plan; or Medicare. You and any family members you wish to cover are NOT eligible for a standard individual health benefits plan if covered by another individual health benefits plan UNLESS you are replacing the other individual health benefits plan by the one for which you are submitting this application. If you do not specify an effective date in the application, your effective date shall be no later than the first day of the month following the month in which the completed application was dated and we receive premium payment directly or through our duly authorized agent UNLESS you submit your application during the October Open Enrollment Period (see F. below). You may apply for coverage for yourself and family members who are covered under a group health plan, group health benefits plan, a governmental plan, a church plan or Medicare during the October Open Enrollment Period IF you wish to replace the current coverage with a more comprehensive individual health benefits plan. The effective date of coverage under the individual health benefits plan in this instance will be January 1 of the calendar year following the October Open Enrollment Period. You SHOULD NOT terminate current coverage until the new coverage is effective.CONDITIONS OF ENROLLMENT -- [APPLICANT] ACKNOWLEDGEMENTS AND AGREEMENTSOn behalf of myself and the dependents listed in this Enrollment/Change Request form, I acknowledge that: I authorize any physician or medical professional, hospital, clinic or other medical care institution, carrier, consumer reporting agency, and any employer to give [Carrier Name], or any consumer reporting agency acting on behalf of [Carrier Name], 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. I agree that, if I revoke this authorization before it expires, such revocation shall not affect any action that [Carrier Name] has taken in reliance on the authorization. I understand I may receive a copy of this authorization if I request one. I agree [Carrier] will provide coverage in accordance with the terms of the contract for the individual [plan] [policy]. I understand that my enrollment and the enrollment of my listed dependents in [Carriers Names] individual [plan] [policy] is effective upon acceptance by [Carriers Name]. 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 [plan] [policy] if premiums are not paid timely.MISREPRESENTATIONSAny 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. Carrier instructions (not to be included in the Nongroup Enrollment/Change Request form when printed by the carrier) Carrier should insert its logo and name where indicated, or leave the table blank, or blacked-out. Carrier must replace bracketed text carrier name with carriers full name throughout the document. Replace on back with appropriate directions if the instructions are not provided on the reverse side. If the carrier refers to the Enrollee/Subscriber using another term such as Member or Applicant or some similar term, replace the term Enrollee/Subscriber with such other term throughout the document. In Section A, carrier may choose to put Civil Union Partner on the same line as Spouse, or on a separate line. In Section A, omit Add/Change Office ID Numbers options if carrier does not offer such options. In Section A, the continuation billing options should be omitted if the carrier does not offer such options. In addition, the phrase ***Billing through the group for a Dependent Under 30 Continuation Election requires agreement by the employer at Section [L] if the carrier does not offer the Integrated continuation coverage option. In Section B, references to the e-mail address should be omitted if the contact option is not offered. At Section B and D, references to primary, ob/gyn and dentist selections, with LOC and NPI numbers should not be included if selections are not an option or a requirement. If a carrier does not assign numbers for each office location, then carriers may indicate that LOC refers to the office location in the selection information, and request that enrollees identify a name for the office location. However, carriers should not request complete office address locations. At Section B and D, omit reference to current patient status, if the carrier does not require the information. At section B and D, omit the request for the Certificate of Creditable Coverage to be submitted with the application if the carrier does not require it. At Section C, insert carrier plan options and deductibles, coinsurance or copayment options, and provide directions for employee/enrollee selections of options as appropriate. Listed options must be consistent with the requirements of N.J.A.C. 11:20-3. At Section D, if the carrier does not require proof of full-time student status provided with the enrollment form and/or proof of disability, omit the directions to attach proof. If Section [E] is omitted, renumber Sections F through L accordingly. At Section I, omit those payment options or modes that are unavailable (but note: carriers must permit payment on a monthly basis). At Section [K], omit reference to agents if the carrier does not use them in the sale of individual policies. The text may be modified to include the specific broker/general agent information the carrier requires. The scope of the information included is limited to information concerning the broker/general agent or agent. In the Instructions, if carrier uses a term other than Member Services, the carrier should insert that term, and must include the appropriate contact phone number. In the Instructions, carrier must insert the procedure to be followed to allow the applicant to secure coverage before the actual ID card is issued. It Instructions, if you require selection of health care providers, insert appropriate information on how the to obtain correct NPI numbers. Note that indicating information is available only through a website is not appropriate. At the Footnote, if a carrier does not utilize an Internal Carrier Form Number, the carrier may omit the reference.  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