New Jersey Department of Health

Health Insurance Continuation Program

PO Box 363

Trenton, NJ 08625-0363

HEALTH INSURANCE INFORMATION	FOR STATE USE ONLY
Record #
FEIN #
W9 VCH

Vendor Maintenance
Name

Social Security Number

Street Address

Telephone Number

City, State, Zip Code

BEFORE WE CAN BEGIN MAKING YOUR INSURANCE PAYMENTS, WE MUST HAVE YOUR ORIGINAL PREMIUM NOTICE(S) FROM YOUR INSURANCE COMPANY, EMPLOYER/FORMER EMPLOYER/UNION THAT INCLUDES INFORMATION ON PREMIUM AMOUNTS, WHEN PAYMENTS ARE DUE, AND WHERE PAYMENTS SHOULD BE SENT.

I hereby authorize having future premium notices sent to the HICP, PO Box 363, Trenton, NJ 08625-0363.

Signature: _____________________________________________________ Date: ______________________
1.	Type of Insurance Coverage;	Individual Group COBRA
COBRA Start	/	/
COBRA End:	/	/
COBRA Extended: Yes No
Group Name if Under COBRA:
A Co-Pay - Amount:
B Deductible - Amount:
2.	Insurance Policy through: Current Employer Former Employer Union Self
3.	Employer or Union Providing Insurance Coverage
Name:
Address:
City, State, Zip:
County:
Contact Person:
Telephone No.:
4.	Names of Other Individuals Covered by This Policy Besides Yourself:
Family Coverage: Family Single Parent/Child
5.	Name of Health Insurance Company:
Address:
City, State, Zip:
County:
Policy Number:
Telephone No.:
Group Number (If Applicable):
6.	Premium Payments
Amount of Premium Payment:	$
Monthly Quarterly Other:
Date Next Premium Payment Due:	/	/
Premium Payments Should be Made Payable to:
Premium Payments Should be Sent to:
Name of Company:
Address:
City, State, Zip:

DHAS-39

MAR 14	IT IS THE APPLICANT'S RESPONSIBILITY TO NOTIFY THE HEALTH INSURANCE CONTINUATION PROGRAM (HICP) OF ANY CHANGE IN INSURANCE PREMIUM, POLICY TYPE, RESIDENCE ADDRESS, OR TELEPHONE NUMBER. ALSO, APPLICANT MUST SEND TO THE HICP THE ORIGINAL OF ALL PREMIUM NOTICES (BILLS) RECEIVED.

DHAS-39, Health Insurance Information

DHAS-39, HICP, health insurance continuation program, health insurance, HIV, AIDS, HIV, STD and TB Services

EWhite

2001-04-04

NJDOH