Aknowledgement For Sole Propritorship Form – Fill Out and Use This PDF

Sole Proprietor and Group of One Attestation Form

I. Business Organization Information:

a. Name of Organization: Tax ID # or SS #:

Primary Business Activity

Address:

City:		State: _____________ Zip:
b. Contact Information for Business Organization
Name:		Fax:
Title:		Phone Number:

II. Sole Proprietor Attestation:

By executing this document, I hereby attest that: (i) the above described business organization is not an association, group purchasing organization or employee leasing organization and was formed for a lawful business purpose and not for the primary purpose of obtaining group insurance; (ii) I am the owner and operator of the above described business organization; (iii) I work a minimum of twenty (20) hours per week for this business organization; I derive the majority of my earned income (non-passive or non-investment) from the income generated from the above business organization; (iv) I seek health coverage only for myself and my eligible dependents through the above described business; (v) I (and my eligible dependents) am the only person eligible for health coverage through the above described business organization; (vi) I will promptly advise Oxford in the event that any of the statements made in this Attestation are no longer accurate.

III. S-Corporations with “One Eligible Employee” Attestation:

By executing this document, I hereby attest that: (i) the above described business organization is not an association, group purchasing organization or employee leasing organization and was formed for a lawful purpose and not for the primary purpose of obtaining group insurance; (ii) I am the sole shareholder of the above described business organization; (iii) I am currently employed by the above described business organization and work a minimum of twenty (20) hours per week for the business organization; (iv) I derive the majority of my earned income (non-passive or non-investment) from services provided to the above business organization; (v) I seek health coverage only for myself and my eligible dependents as listed on my enrollment form; (vi) I (and my eligible dependents) am the only person eligible for health coverage through the above described business organization; and (vi) I will promptly advise Oxford in the event that any of the statements made in this Attestation form are no longer accurate.

IV. Tax Forms and other Documents (applicable to both Sole Proprietors and S-Corporations):

By executing below, I agree to provide upon request appropriate tax forms to Oxford to validate the eligibility status. Before application will be considered, the applicant must execute this Attestation Form and provide the tax information and related documents indicated on the attached correspondence. Oxford reserves the right to modify these documentation and eligibility requirements in the future.

The undersigned certifies that, to the best of his or her knowledge and belief, and under penalty of perjury, the information listed above is true and complete.

X.

Signature of Applicant

Date

Insurance products are underwritten by Oxford Health Insurance, Inc.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation.

NY-07-134

9503 R2