Model Certificate of Individual Health Insurance Coverage
*IMPORTANT--This certificate provides evidence of your prior health coverage. You may need to furnish this certificate if you become eligible under a group health plan that excludes coverage for certain medical conditions that you have before you enroll. This certificate may need to be provided if medical advice, diagnosis, care, or treatment was recommended or received for the condition within the 6 month period prior to your enrollment in the new plan.
If you become covered under a group health plan, check with the plan administrator to see if you need to provide this certificate. You may also need this certificate to buy, for yourself or your family, an insurance policy that does not exclude coverage for medical conditions that are present before you enroll.
- Date of this certificate:
- Name of policyholder:
- Identification of policyholder:
- Name of any dependents to whom this certificate applies:
- Name, address, and telephone number of issuer responsible for providing this certificate:
- For further information, call:
- If an (all) individual(s) identified in items 2 and 4 has (have) at least 12 months of credible coverage (disregarding periods of coverage before a 63-day break), check here _______ and skip items 8 and 9.
- Date coverage began:
- Date that a substantially completed application was received from the policyholder:
- Date coverage ended
(Or check here if coverage is continuing as of the date of this certificate:____)
NOTE: Separate certificates will be furnished if information is not identical for the policyholder and each dependent.