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Carrier Agreements

Oscar New Jersey Application Agreement

Member's Signature

I represent that all the information supplied in this application is true and complete. I hereby agree to the Conditions of Enrollment set forth in this Enrollment/Change Request form

CONDITIONS OF ENROLLMENT -- [APPLICANT] ACKNOWLEDGEMENTS AND AGREEMENTS

On behalf of myself and the dependents listed in this Enrollment/Change Request form, I acknowledge that:

  1. I authorize any physician or medical professional, hospital, clinic or other medical care institution, carrier, consumer reporting agency, and any employer to give Oscar Garden State

Insurance Corporation, or any consumer reporting agency acting on behalf of Oscar Garden State Insurance Corporation, information pertaining to employment, other health coverage, and medical advice, treatment or supplies for any physical or mental condition relevant to me or a minor dependent applying for coverage. I agree that this authorization shall be valid for 30 months from the date I sign this Enrollment/Change Request form, unless revoked at an earlier date.

  1. I agree that, if I revoke this authorization before it expires, such revocation shall not affect any action that Oscar Garden State Insurance Corporation has taken in reliance on the authorization.

  2. I understand I may receive a copy of this authorization if I request one.

  3. I agree Oscar Garden State Insurance Corporation will provide coverage in accordance with the terms of the contract for the individual policy.

  4. I understand that my enrollment and the enrollment of my listed dependents in Oscar Garden State Insurance Corporation’s individual policy is subject to acceptance by Oscar Garden State

Insurance Corporation's.

  1. I agree that the provision of coverage and benefits is contingent upon payment of premiums and may be terminated in accordance with the terms of the individual policy if premiums are

not paid timely.

MISREPRESENTATIONS

Any person who includes any false or misleading information on a Nongroup Enrollment/Change Request Form is subject to criminal and civil penalties.