By signing this form, I acknowledge that this information may be subject to verification. I agree to provide Cigna + Oscar with any information
necessary to do so. I also understand that failure to meet the above conditions may result in denial or termination of group health coverage for
the above-named company. I understand that, under state insurance law, any person who knowingly and with the intent to defraud any
insurance company or other person files an application for insurance or statement of claim containing any materially false information, or
conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime,
and may also be subject to a civil penalty.
Full name
Business name
Title
Corporate Officer / Proprietor /
Partner Verification Statement
Section I: Identifying information
Section III: Signature
Signature Printed name Date (mm/dd/yyyy)
Sign here
For business owners, officers, proprietors and partners enrolling in Cigna + Oscar coverage who are not on the business’s tax documents.
This form must be completed and signed by you, the business owner, officer, proprietor or partner. The information you provide will be used to
verify your affiliation with the business and determine your eligibility for Cigna + Oscar coverage.
Telephone number State of incorporation
I attest that, although my name does not appear on the tax documents of the above-named company, the following is true:
• I am a manager/member, partner, officer or sole proprietor of the above-named company.
• I actively work at this company on a permanent basis and work at least 30 hours per week.
• I draw wages, dividends, or other distributions from this company on a regular basis.
• I do not derive substantial earned income from any other employer and am not eligible for other employer-sponsored coverage as
a subscriber.
• I will provide additional ownership/business validation documentation, including IRS forms, as requested.
Section II: Eligibility attestation
Cigna + Oscar coverage is insured by Cigna Health and Life Insurance Company.
Benefits administered by Oscar Health Administrators. Pharmacy benefits are provided by Express Scripts, Inc.
