CERTIFICATION OF SOLE PROPRIETOR STATUS
FOR COVERAGE WITH HIP HEALTH PLAN
OF NEW YORK

I____________________________,  hereby affirm that I am self-employed, on a full-time basis, working 20 or more hours a week. 

Printed Name

As proof of my employment status, I have enclosed a copy of my most recent federal tax return (which includes a complete schedule C). I agree to notify HIP Health Plan of New York (hereinafter, "HIP") immediately if my circumstances change and I am no longer self-employed.

I acknowledge and agree that it is a fraudulent act subject to criminal and civil penalties to knowingly and with intent to defraud file an application for insurance (including any supporting certificates) containing any materially false information, or which conceals for the purpose of misleading, information concerning any fact material thereto. I further acknowledge and agree that filing a false or misleading insurance application with HIP shall render any health insurance contract entered into HIP null and void.

I certify that this certification and my enclosed federal tax return are true, correct and complete.

_____________________________
Signature

_____________________________
Date

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