Certification of owner

Each owner must complete this form if the owner is currently eligible for coverage under the health plan, but is NOT listed on the Quarterly Wage Detail Report (QWDR) or the QWDR shows less than full-time wages for owner(s

Please make copies of the blank form if there are multiple owners, and submit a completed form for each owner.  Click here to send this form to another 

I, the undersigned, hereby certify that I am an Owner and eligible employee of (the “Company Name”) and currently work no less than the minimum number of hours required by the Company’s Group Agreement with Priority Health and/or Priority Health Insurance Company collectively, “Priority Health” 

I hereby certify that the information I have provided above is true and complete to the best of my knowledge and that Priority Health has issued or will issue health insurance coverage to me and my eligible dependents based on this certification. If the information is found to be incorrect; I understand that my coverage may be rescinded.