Provide a valid letter of coverage on company letterhead from the insured’s employer. The letter must include contact information, current date, and t...
Download insurance products. Another concern is that a relatively narrow view of what constitutes cyber risk may be prompting many insurers to focus their marketing ...
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County of Humboldt Human Resources/Risk Management 825 5th Street Room 100 Eureka CA 95501
How to Provide Proof of Health Insurance Coverage To begin or continue receiving the County Insurance Opt Out differential payment you must do one of the following: Provide a valid letter of coverage on company letterhead from a credible insurer. The letter must include contact information, current date, and the names of the individuals covered. Or Provide a valid letter of coverage on company letterhead from the insured’s employer. The letter must include contact information, current date, and the names of the individuals covered. Or Complete this form. Section 1 is for the County Employee. It is important to print legibly. #1A #1B #1C #1D
Print your name. Print your daytime phone number. Print the county department you work for. Sign and date.
Section 2 is for the Insurance Company or Employer of the Insured. #2A #2B #2C #2D #2E #2F #2G
Print the Insurance Company or Employer of the Insured. Print the contact name and phone number of the person completing the form. Print the date the form is being completed. Print the coverage effective date. Print the job title of the person completing the form. List/Print the full names and dates of birth for all of the insured. Sign and date.
Note:
The form is typeable for your convenience.
Section 3 is for Risk Management. Return the completed documentation to Risk Management Via Fax, Inter-Office Mail, or Post Mail at the address above. Human Resources HR Phone 707-476-2349 Fax 707-445-7285
This form can be used as an option to show proof of coverage in place of asking the employer or insurance carrier to provide proof on letterhead. It is not necessary for Section 2 to be completed in addition to a letter. You will be notified if additional information is required.
Section 1 Employee Complete This Section and Sign Below 1A
1B
1C
Employee Name/Print Only
Daytime Phone Number
Employee Department
1D
Email Address
(optional)
Employee Signature Date Signed
Section 2 Employer or Insurance Carrier Complete This Section 2A
2B
2C
Name of Company/Employer
Contact Name and Phone Number
Today's Date
2D
2E
Coverage Effective Date
Job Title of Person Completing This Form
List Full Names and Dates of Birth for the Insured and Dependents Below:
2F
Signature and Job Title of Person Completing This Form
Date Signed 2G
Section 3 County of Humboldt Section-3 Approved Notes:
