How to Provide Proof of Health Insurance Coverage

Provide a valid letter of coverage on company letterhead from the insured’s employer. The letter must include contact information, current date, and t...

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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

www.co.humboldt.ca.us/hr

Job Hotline 707-445-2357

Risk Management RM Phone 707-268-3669 Fax 707-268-2546

www.co.humboldt.ca.us/riskmanager

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:

Not Approved

Date

Initials