Applications and Required Documentation

ALL ENROLLMENT APPLICATIONS AND REQUIRED DOCUMENTATION MUST BE RECEIVED BY THE 25TH OF THE MONTH PRIOR TO THE ENROLLMENT EFFECTIVE DATE.

PLEASE BE ADVISED THAT THE ENROLLMENT EFFECTIVE DATE CAN ONLY BE THE FIRST OF THE MONTH

REQUIRED DOCUMENTATION / SUBMISSION CHECK LIST
NY SOLE PROPRIETOR

NOTE: PLEASE MAKE CERTAIN THAT ALL REQUIRED FORMS AND APPLICATIONS ARE FULLY COMPLETED, SIGNED AND DATED.


1) NY Sole Proprietor Application
2) NY Member Enrollment Form
3) Sole Proprietor Attestation Form
4) First month's premium check made payable to: OXFORD HEALTH PLANS

AND

5) Documentation for Sole Proprietor in Business for more than one (1) year.

• Form 1040:......................
.Please provide the first two pages of your Form 1040*

*NOTE: W-2 income on line 7 of Form 1040 cannot be more than 49.9% of income on Schedule C-EZ (line 1) or Schedule C (line 7) or Form 1120S (line 6).

In addition, please provide at least one of the following documents from the most recent tax year (2007):

• Schedule C-EZ: Net Profit From Business (Sole Proprietorship)

• Schedule C: .Profit & Loss From Business (Sole Proprietorship)
 
• Form 1120S: U.S. Income Tax Return for an S Corporation*  
..*Schedule K-1of Form 1120S must show 100% stock ownership by you.

OR

6) At least one of the following documents for Sole Proprietor in Business for less than one (1) year.

• Business Certificate and/or Filing Receipt

• Assumed Business Name Filing Receipt

• NY State Business License

• Copy of Business Bank Statement
...(for sole proprietors or independent contractors only)

Please mail all required documentation and your first month's premium check
(made payable to OXFORD HEALTH PLANS) to:

PLCSI
Dennis M. Supraner, President
45 Knollwood Road • 2nd Floor
Elmsford, NY 10523
914-592-6505

Please allow at least 5 business days for mailing.