INSURANCE CREDIT REQUEST

Attached is the Insurance Premium Credit Request form. Complete the form, attach proof of the
monthly insurance premium amount paid by the employee, (copy of check stub, statement from
employer, etc.), names of all individuals covered by the policy (statement from your insurance company
or copy of insurance policy showing all individuals covered on policy) and return the form to the Office
of Recovery Services (ORS) at the address below.

In accordance with Utah Administrative Rule 527-201-8(2), if an insurance credit is applicable, it will be
applied “. . . beginning the first of the month following the date ORS/CSS receives the completed
Insurance Premium Credit Request . . .” and the required verification of the coverage and costs.

U.C.A. 78B-12-212(8) requires parents ordered to maintain insurance coverage for their minor child(ren)
to notify and provide verification of that coverage to ORS ". . . upon initial enrollment of the dependent
child, and after initial enrollment on or before January 2 of each calendar year." Also per U.C.A. 78B-12-
212(8), changes to insurance carrier, premium paid, or benefits must be reported to the office ". . .
within 30 calendar days of the date the parent first knew or should have known of the change." Failure
to comply with these requirements may result in denial of the insurance credit pursuant to U.C.A. 78B-
12-212(10).

If you have questions regarding this matter, please call ORS at (801)536-8500.

Send all documentation and correspondence to the following address:

Office of Recovery Services

PO Box 45033
Salt Lake City, UT 84145-0033

Attachment
Your Full Name: ____________________________
Your ORS Case No.: _________________________

INSURANCE PREMIUM CREDIT REQUEST

In order to process an insurance credit request, ORS must receive your completed Insurance Premium
Credit Request form including proof of the insurance premium amounts paid and verification of
coverage documenting all individuals covered under the policy. If the form is incomplete or the
required verification is not provided with the submitted request, you may not receive an insurance
credit.

MEDICAL INSURANCE POLICY:

Policyholder Name:____________________________________________________________________
Policyholder Date of Birth: _______________________________________________________________
Insurance Company Name: ______________________________________________________________
Insurance Company Address:_____________________________________________________________
_____________________________________________________________________________________
Insurance Company City: ___________________________ State: _________________ ZIP: ________
Insurance Company Phone: _______________________ Date Coverage Began: ___________________
Policy Number: __________________________ BCBS Code: __________________________________
Premium Amount:____________________
Frequency:  Weekly  Biweekly  Semi-monthly  Monthly
Monthly Cost to Policyholder to Insure: Self: ____________ Double: __________ Family: ___________
Does coverage extend to dependents living outside of the state where Policyholder resides? Yes  No
List the name of each person covered on the policy and the relationship to the Policyholder:
NAME RELATIONSHIP NAME RELATIONSHIP
______________________ _______________ ______________________ _______________
______________________ _______________ ______________________ _______________
______________________ _______________ ______________________ _______________
______________________ _______________ ______________________ _______________

Additional types of coverage included in Medical Insurance Policy:  Dental  Vision  Pharmacy

DENTAL INSURANCE POLICY:

Policyholder Name:____________________________________________________________________
Policyholder Date of Birth: _______________________________________________________________
Insurance Company Name: ______________________________________________________________
Insurance Company Address:_____________________________________________________________
_____________________________________________________________________________________
Insurance Company City: ___________________________ State: _________________ ZIP: ________
Insurance Company Phone: _______________________ Date Coverage Began: ___________________
Policy Number: __________________________ BCBS Code: __________________________________
Premium Amount:____________________
Frequency:  Weekly  Biweekly  Semi-monthly  Monthly
Monthly Cost to Policyholder to Insure: Self: ____________ Double: __________ Family: ___________
Does coverage extend to dependents living outside of the state where Policyholder resides? Yes  No
List the name of each person covered on the policy and the relationship to the Policyholder:
NAME RELATIONSHIP NAME RELATIONSHIP
______________________ _______________ ______________________ _______________
______________________ _______________ ______________________ _______________
______________________ _______________ ______________________ _______________
______________________ _______________ ______________________ _______________

Additional types of coverage included in Medical Insurance Policy:  Dental  Vision  Pharmacy

VISION INSURANCE POLICY:

Policyholder Name:____________________________________________________________________
Policyholder Date of Birth: _______________________________________________________________
Insurance Company Name: ______________________________________________________________
Insurance Company Address:_____________________________________________________________
_____________________________________________________________________________________
Insurance Company City: ___________________________ State: _________________ ZIP: ________
Insurance Company Phone: _______________________ Date Coverage Began: ___________________
Policy Number: __________________________ BCBS Code: __________________________________
Premium Amount:____________________
Frequency:  Weekly  Biweekly  Semi-monthly  Monthly
Monthly Cost to Policyholder to Insure: Self: ____________ Double: __________ Family: ___________
Does coverage extend to dependents living outside of the state where Policyholder resides? Yes  No
List the name of each person covered on the policy and the relationship to the Policyholder:
NAME RELATIONSHIP NAME RELATIONSHIP
______________________ _______________ ______________________ _______________
______________________ _______________ ______________________ _______________
______________________ _______________ ______________________ _______________
______________________ _______________ ______________________ _______________

Additional types of coverage included in Medical Insurance Policy:  Dental  Vision  Pharmacy

PHARMACY INSURANCE POLICY:

Policyholder Name:____________________________________________________________________
Policyholder Date of Birth: _______________________________________________________________
Insurance Company Name: ______________________________________________________________
Insurance Company Address:_____________________________________________________________
_____________________________________________________________________________________
Insurance Company City: ___________________________ State: _________________ ZIP: ________
Insurance Company Phone: _______________________ Date Coverage Began: ___________________
Policy Number: __________________________ BCBS Code: __________________________________
Premium Amount:____________________
Frequency:  Weekly  Biweekly  Semi-monthly  Monthly
Monthly Cost to Policyholder to Insure: Self: ____________ Double: __________ Family: ___________
Does coverage extend to dependents living outside of the state where Policyholder resides? Yes  No
List the name of each person covered on the policy and the relationship to the Policyholder:
NAME RELATIONSHIP NAME RELATIONSHIP
______________________ _______________ ______________________ _______________
______________________ _______________ ______________________ _______________
______________________ _______________ ______________________ _______________
______________________ _______________ ______________________ _______________

Additional types of coverage included in Medical Insurance Policy:  Dental  Vision  Pharmacy

Printed Name: _______________________________ Phone Number: __________________________

Signature (required): __________________________________ Date: __________________________

Send all documentation and correspondence to the following address:

Office of Recovery Services

PO Box 45033
Salt Lake City, UT 84145-0033