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SEH Program Forms
 
Standard Application

NOTE: The standard application is for use with applications for new business effective March 1, 2021 and later by carriers that wish to offer an electronic payment option.

The Certification form included with the January 1, 2018 application must be used with this application that allows electronic premium payment. 

  • Application for a Small Group Health Benefits Policy: MS Word or PDF
 
Standard Application and Certification

NOTE: The standard application and certification forms are for use with applications for new business effective January 1, 2018 and later.

  • Application for a Small Group Health Benefits Policy: MS Word or PDF
  • Employer Certification for use with Small Business Health Options program (SHOP):
    MS Word or PDF
 
Standard Plans

NOTE: Below are the Standard forms that MUST be used for new business to be issued on or after January 1, 2024.
 

NOTE: Below are the Standard forms that MUST be used for new business to be issued on or after January 1, 2023.
 

NOTE: Below are the Standard forms that MUST be used for new business to be issued on or after January 1, 2022.
 

NOTE: Below are the Standard forms that MUST be used for new business to be issued on or after January 1, 2019.
 

NOTE: Below are the Standard forms that MUST be used for new business to be issued on or after January 1, 2018.
 

NOTE: Below are the Standard forms that MUST be used for new business to be issued on or after May 16, 2017.
 

NOTE: Below are the Standard forms that MUST be used for new business to be issued on or after January 1, 2017.
 

NOTE: Below are the Standard forms that MUST be used for new business to be issued on or after January 1, 2016.
 
NOTE: Below are the Standard forms that MUST be used for new business to be issued on or after January 1, 2015.
 

NOTE: Below are the Standard Small Employer Application and Certification Forms that MUST be used for new business to be issued on or after January 1, 2017.
 

NOTE: Below are the Standard Forms that MUST be used for new business to be issued on or after January 1, 2014.
 

NOTE: Below are the Standard Forms that are operative January 1, 2013 and can no longer be issued.

 
Reporting Forms
 
Filing Deadlines

Frequency

Deadline

Exhibit

Report Description

Reference

Quarterly
[60 days following the close of each quarter]

Mar 1
Jun 1
Sep 1
Dec 1

NA

Quarterly Enrollment

N.J.A.C. 11:21-7.12

Annual*

Mar 1

Exhibit BB 1, 2

Certification of the use of the standard plans and marketing material

N.J.A.C. 11:21-4.2

Annual

Apr 1

Exhibit CC

Market Share Report

N.J.A.C. 11:21-10.3

Annual

Aug 1

Exhibit GG##

Loss Ratio Report##

Refund or Credit Plan (if necessary)##

N.J.A.C. 11:21-7A.3

N.J.A.C. 11:21-7A.5

 *Exhibit BB (Parts 1 and 2) must also be filed upon market entry and prior to amending plans

##These reports are made to the Department of Banking and Insurance not the SEH Board 


 
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State of New Jersey
New Jersey Department of Banking and Insurance