![]() Write the phone number of the company official who signed the form in this field. ![]() Print the title of the company official who signed the form in this field. Write the date that you sign the form in this field. Please write the month and year for when the remaining hours in the employee’s hours bank account expired or will expire.Īll employers need to complete the bottom of Section B.Īn official representative of the company needs to sign this document. Date reserve hours ended or will be used?.Please indicate if the applicant currently has health coverage based on the remaining hours in the employee’s hours bank account. If yes, does the applicant have hours remaining inreserve?.If you check no, please also fill out the section for “Employer Group Health Plans ONLY”. Please check yes or no if the applicant was covered under an hours bank arrangement. Is (or was) the applicant covered under an hours bank arrangement?. ![]() If you’re an employer with an hours bank arrangement, complete the section called “For Hours Bank Arrangements ONLY” Write the start and end dates that your group health plan was primary payer for the applicant. If you’re a large group health plan and the applicant is disabled, please list the timeframe (all months) that your group health plan was primary payer.If the employee is still employed, enter the month and year of the current date.Ĭurrent employment is active working status. It may be the applicant or another person related to the employee, such as a spouse or family member with disabilities.Įnter the month and year of the start of the employment in the “From” box.Įnter the month and year of end of the employment in the “To” box. Write the start and end dates of the employment for the employee in which the applicant is related. When did the employee work for your company?. ![]() Write the month and year the group health plan coverage ended for the applicant.
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