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Overage Dependent Enrollment FormEmployer: ___ Group / Policy # : ___Personal Information Employee Last NameEmployee First NameCertificate Number______Dependant Last NameDependant First Name_________Date
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Who needs n-4402 self funded group?
01
Employers or organizations looking to provide self-funded health insurance benefits to their employees.
02
Groups or associations looking to collectively fund their own health insurance coverage.
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What is n-4402 self funded group?
N-4402 self funded group is a form used to report information about self-funded groups that provide health coverage.
Who is required to file n-4402 self funded group?
Employers or administrators of self-funded groups are required to file n-4402.
How to fill out n-4402 self funded group?
N-4402 self funded group can be filled out electronically or on paper, providing all required information accurately.
What is the purpose of n-4402 self funded group?
The purpose of n-4402 self funded group is to report information about the health coverage provided by self-funded groups.
What information must be reported on n-4402 self funded group?
Information such as the name and address of the self-funded group, number of participants, and type of coverage provided must be reported.
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