• Health Benefits Affidavit

    Please complete this affidavit to declare your eligibility and dependents for health benefits coverage.
  • Format: (000) 000-0000.
  • Type of Health Benefits Requested*
  • Are any dependents covered by another health insurance plan?*
  • Powered by Jotform SignClear
  • Should be Empty:
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{form_title}<\/h3>\n <\/td>\n

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\n Applicant's Full Name\n <\/td>\n \n {q2_fullname0}\n <\/td>\n <\/tr>
\n Email Address\n <\/td>\n \n {q3_email1}\n <\/td>\n <\/tr>
\n Phone Number\n <\/td>\n \n {q4_phone2}\n <\/td>\n <\/tr>
\n Home Address\n <\/td>\n \n {q5_address3}\n <\/td>\n <\/tr>
\n Employment Status\n <\/td>\n \n {q6_dropdown4}\n <\/td>\n <\/tr>
\n Type of Health Benefits Requested\n <\/td>\n \n {q7_checkbox5}\n <\/td>\n <\/tr>
\n List Your Dependents (if any)\n <\/td>\n \n {q8_widget_ConfigurableList6}\n <\/td>\n <\/tr>
\n Are any dependents covered by another health insurance plan?\n <\/td>\n \n {q9_radio7}\n <\/td>\n <\/tr>
\n If yes, please provide details of the other coverage (company name, policy number, covered individuals)\n <\/td>\n \n {q10_textarea8}\n <\/td>\n <\/tr>
\n Attestation: I affirm that the information provided in this affidavit is true and complete to the best of my knowledge. I understand that providing false information may result in loss of coverage or other consequences. I agree to notify the benefits administrator of any changes.\n <\/td>\n \n {q11_widget_TermsAndConditions9}\n <\/td>\n <\/tr>
\n Signature of Applicant\n <\/td>\n \n {q12_signature10}\n <\/td>\n <\/tr><\/tbody><\/table><\/td>\n <\/td>\n <\/tr>
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<\/td>\n \n You can {edit_submission}<\/span> and {all_submissions}<\/span> easily.\n <\/td>\n <\/td>\n <\/tr>
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<\/td>\n <\/tr><\/tbody><\/table><\/div>\n \n <\/body><\/html>\n","bodyRevised":"0","branding21Email":"1","dirty":"","dirtyEmail":"0","from":"{q2_fullname0}","hideEmptyFields":"1","html":"1","lastQuestionID":"1","name":"Notification 1","newDisableFlow":"1","pdfattachment":"","replyTo":"{q3_email1}","sendOnEdit":"1","sendOnSubmit":"1","subject":"Re: {form_title} - {q2_fullname0}","to":"template+laurelwood@jotform.com","type":"notification","uniqueID":"260481084174052","uploadAttachment":""},{"aiEditedEmail":"0","aiGeneratedEmail":"0","attachment":"","body":"\n