Applicant’s Social Security Number

Aetna Advantage Plans for Individuals,

Families and Self-Employed Application ID Number
Attestation of Child’s Eligibility
A. Instructions
● Please complete and submit this form with the Application for the child.
● Please PRINT clearly.
● Attestation must be completed by the parent or legal guardian in blue or black ink. No pencil or correction fluid. (A photocopy of this
application will not be accepted.)
● The parent or legal guardian must complete the application. The parent or legal guardian is responsible to ensure that the information on the
application is correct, complete, and truthful.
● Aetna requires a copy of my child’s birth certificate, adoption decree or legal documentation of responsibility for purposes of
dependent verification.
● The parent or legal guardian must submit the required documentation with the application and this attestation. Failure to do so will result in your
application being closed.
● Note: A separate attestation form is required for each child under the age of 19.

B. Required Documentation for Proof of Residency and Proof of Age. (Please submit one verification document for (1) and (2) below with the
Application for the child.)
1. Proof of Residency: Documentation required validating the residency of the child in the state for which you are seeking health insurance.
Documentation must show residential property address and name of one parent or legal guardian.
Examples:
• Copy of school enrollment records including the child’s name and address
• Copy of lease or mortgage document
• Copy of utility bill with residential address
• Copy of credit card statement
• Copy of bank statement
• Copy of drivers license
2. Proof of Age: Documentation required validating child’s date of birth and the name of parent or legal guardian.
Examples:
• Birth Certificate
• Adoption Certificate
• Legal Guardianship papers
C. Child Eligibility
Child to be covered Name

Parent’s Name E-mail Address

Mailing Address (Include Apartment Number, if applicable.) Telephone Numbers

Number, Street U Home ( )
County U Work ( )
City, State, ZIP Code U Cell ( )

GR-67466-52 (12-10) This form is not proof of coverage. R-POD

D. Signature Required – This attestation form must be signed by the parent or legal guardian
I attest that the following information is true and complete:
1. The child listed on this form is my legal dependent. Yes No
2. I am applying for coverage for my child for the following reason(s) (check all that apply):
Annual Open Enrollment Period Defined by the State
Moved to this new State on U U (mm/dd/yyyy)
Effective Date is Child's Birth Date
Loss of current coverage for child.
Explain:
U

Court Mandated Coverage. Date of court order U U (mm/dd/yyyy)

3. Is the child referenced above a "non-citizen resident" of the United States? Yes No
If Yes, has the child resided within the United States for the past six (6) consecutive months? Yes No
4. I read and write English. Yes No
Dependent coverage obtained through intentional misrepresentation or fraud will be terminated and claims incurred for the dependent will
become the financial responsibility of the undersigned applicant.
I understand that falsifying information for the purpose of obtaining health insurance for my child with intent to defraud any insurance
company, including concealing information for the purpose of misleading any fact material thereto, commits a fraudulent insurance act, which
is a crime and subjects such person to criminal and civil penalties. I understand that Aetna will pursue cases of suspected insurance fraud
and may report all activities related to such investigations to state regulators and law enforcement agencies.
By signing below, I agree to the statements listed above and attest that all information supplied on this form is true, complete and correctly
recorded by me and that any misrepresentation and/or mistake in such information will be reason for cancellation/termination of the coverage
for my dependent(s) for which I am applying.
In the state of California only:
A Premium surcharge of 20% may be applied monthly for the first 12 months of coverage under a child only plan if evidence of continuous health insurance
coverage for the past 90 days has not been supplied at the time of application.
Applicant/Parent or Legal Guardian Name (Please print) Today’s Date

Signature

GR-67466-52 (12-10) 2