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| Home > Insurance Division > Health Insurance Programs > IHC > Forms |
| IHC Program Forms |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2026) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2025) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2024) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2023) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2022) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2019) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2018) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After May 16, 2017) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
| Non-Group Conversion Form |
MS Word |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2017) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
| Non-Group Conversion Form |
MS Word |
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| Standard Plans, Riders and Enrollment Forms (For Plans Issued on or After January 1, 2016) |
| Plans A/50, B, C, and D (Exhibit A) |
MS Word |
| HMO Plan (Exhibit B) |
MS Word |
| Explanation of Brackets Plans A/50 through D and HMO (Exhibit C) |
MS Word |
| Compliance and Variability Rider (Exhibit D) |
MS Word |
| Non-Group Enrollment Form |
MS Word |
| Non-Group Conversion Form |
MS Word |
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| *This column indicates the frequency for filing the report. A= annually. B= biannually, in odd-numbered years. |
| **NLT= no later than the date specified, unless the Board issues a bulletin extending a deadline. The Board issues bulletins to carriers on the Board’s mailing list and posts bulletins to the Board’s website. |
| ***There is no form; the rules specify the information that must be submitted. |
| †Exhibit E also must be filed before marketing, issuing or renewing any standard policy form. |
| ††These reports must be filed prior to using the rates; rates cannot be stated for a period exceeding 12 months. For more information, see the Common Rate Filing Questions under the Rate Filing Resources for Carriers section at www.state.nj.us/dobi/lifehealthactuarial/rateinfo/. |
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