Fillable Attestation I certify Aetna is the only carrier (Dickerson Insurance Services)

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Attestation I certify Aetna is the only carrier (Dickerson Insurance Services)

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The Attestation I certify Aetna is the only carrier (Dickerson Insurance Services) form is 1 page long and contains:

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  • 1 check-box
  • 4 other fields

Country of origin: US
File type: PDF

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Attestation
I certify Aetna is the only carrier offering
health coverage to my employees.
Employer signature Print name
Legal company name Date
Broker signature Date
Any person who includes any false or misleading information on an application, enrollment form
or certification for health benefits plan is subject to criminal and civil penalties.
Aetna reserves the right to audit all information provided.
GR-69207 (9-20)
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Attestation I certify Aetna is the only carrier (Dickerson Insurance Services)

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Completed 1 June 2021

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