Common Ownership Certification /

Please complete, sign and submit the Common Ownership Certification.

This form must be filled out and returned even if you do not have multiple companies.

If the space provided is not adequate for your response, please use additional paper and attach to this form.

COMMON OWNERSHIP CERTIFICATE
The Health Insurance Portability and Accountability Act of 1996 states that all persons treated as a single employer under subsection (b), (c), (m), or (o) of section 414 of the Internal Revenue Code of 1986 shall be treated as one employer.
Please list all companies that would qualify as one employer under the above referenced sections of the Internal Revenue Code.
Group Number:«CustomerNumber»
Name of Group(s) on Policy:
Primary Business Location:
Please provide the most current tax documentation for group(s) on Policy and reconcile with the coding provided on the Employer Information Form.
Business Name / Federal Tax ID # / # of Eligible Employees / Check if on Policy
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I certify that the group named above is a single employer under section 414 of the Internal Revenue Code of 1986 (26 U.S.C. Section 414 (b), (c), (m), or (o)), and under any applicable state law. I further certify that there are no other affiliated entities other than the ones listed above who are eligible to file a combined state tax return. I represent that, to the best of my knowledge, the information I have provided is accurate and truthful. I understand that any misrepresentation or fraudulent statement may result in rescission of the group policy, termination of coverage, an increase in premiums retroactive to the policy date, or other consequences as permitted by law.
Name (please print) & Title: / Signature: / Date:
Type of Business Organization(Check box below)
Sole Prop. Farm S-Corp. C-Corp Partnership (LLP) LLC Non-Profit Corp.
1. Is Group continuing to meet the contribution guidelines defined in your benefit contract?
Circle: YES / NO
2. Do You Offer Coverage to Your Contracted 1099 Employees? *If Yes, Please provide most recent 1099 forms if applicable.
Circle: YES / NO / N/A
3. Do You file a consolidated tax return as an affiliated group? *If Yes, Please provide most recent Form 851.
Circle: YES / NO
Please read the below boxes carefully and submit the requested information that pertains to your business.
We Require The Most Recent Copy of your State Quarterly Wage & Tax Report (QWR)*
**Please List on the Wage & Tax Form Next to Each Employee:
State of Residency & Status Code(from the list below),
Date of Hire or Termination Date
(If Applicable).
The Submitted Documents Must Identify All Employees, Owners, Partners & Contracted Employees for Your Business, Not Only Those Who have Coverage with United Healthcare. / If your company does not file a Quarterly Wage and Tax (QWR) form or you have employeeswho are not reflected on the QWR,please submit from the following applicable tax documentation.
  • Sole Proprietorship – IRS Schedule C (Form 1040) or Schedule F (farms)
  • S-Corporation - IRS Schedule K-1 (Form 1120S).
  • C-Corp – IRS Form 1120 (pg 1 & 2), including Schedule “E” & Schedule K #5.
  • Partnership – IRS Schedule K-1 (Form 1065)
  • LLC: - Appropriately filed IRS Schedule(s)
  • Non-Profit - Most Recent Quarter Federal Form 941 and current 2-week payroll
  • Contracted Employees 1099 Tax Form for all Contracted Employees (only if you offer coverage to contracted employees.)
  • “New Hire Only” -Most Recent (2 weeks) Payroll Report

STATUS CODES
A = Enrolled Applicant ( subscriber ) / S = Employee(s) who is covered through his/her spouse employer plan
M = Employee(s) covered under Medicare / O = Other coverage (clarify group or individual or Military, parental coverage)
T = Terminated employee(s) - no longer works for the employer / D = Decline - (i.e. due to Cost, doesn’t want coverage ) Only list a “D” if the employee is full time with no other coverage or waiver reason.
P = Part-time employee(s) who works less than the required full time hours(also includes Temporary and seasonal employees) / L = Employee(s) not actively working due to leave of absence or other reason.
( ex: disability)
*Please provide last tax form/payroll that employee is listed on
W = Full Time employee(s) who is in the policy’s waiting period- indicate date of hire and when the employee will be eligible for coverage / C = Employee(s) with continued coverage under State Continuation or Federal
law ( Cobra) – Identify cobra/continuation start date and if from a prior employer or if coverage provided by your company.

10/9/2018