Get Chapter 375 - Coverage Of A - State Of New Jersey

The Chapter 375 application allows eligible dependents to receive health care coverage under the State Health Benefits Program (SHBP) or School Employees’ Health Benefits Program (SEHBP) until age 31. This guide provides you with a step-by-step approach to complete the application accurately and efficiently online.

Follow the steps to fill out the Chapter 375 application online.

1. Use the ‘Get Form’ button to access the Chapter 375 application, enabling you to begin filling out the form.
2. Fill in the 'Covered Child’s Information' section completely. Print or type the child’s Social Security Number, last name, first name, middle initial, date of birth, gender, home telephone number, and street address. Ensure to specify if the child is a full-time student and attach the necessary transcript if they are studying outside New Jersey.
3. Complete the 'Covered Parent’s Information' section. Provide the covered parent's Social Security Number, last name, first name, date of birth, home telephone number, street address, and indicate the relationship to the child. Make sure all details are accurate and thorough.
4. If the billing address differs from the child's address, fill in the 'Billing Address' section with the required information so that correspondence reaches the correct location.
5. In the 'Coverage Election' section, choose whether to enroll the child in the same health plan as the covered parent by checking the appropriate box. If selecting an HMO, include the Primary Care Physician's ID number.
6. Both the covered child and the covered parent must read the certification statement carefully and provide their signatures along with the date of completion. Remember that misrepresentation can lead to penalties.
7. After completing the form, submit it along with any required documentation to the New Jersey Division of Pensions and Benefits. Do not send payment with the application; the covered parent will be billed directly.

Complete your Chapter 375 application online today for a seamless health benefits experience.