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HB-0077-0807
#08-163
JULY 10, 2008
STATE OF NEW JERSEY
DEPARTMENT OF THE TREASURY
DIVISION OF PENSIONS AND BENEFITS
NEW JERSEY STATE HEALTH BENEFITS PROGRAM
PO Box 299 Trenton, New Jersey 08625-0299
RESOLUTION
A RESOLUTION to authorize participation in the New Jersey State Health Benefits Program Act of the State of New Jersey,
BE IT RESOLVED:
1. The ~C~~p~~orE~~ CQv~ev~--Y Slal,SoclaISecudlyLO.Numbe,
hereby elects to participate in the Health Program provided by the New Jersey State Health Benefits Act of the State of New
Jersey (N,J,SA 52:14-17,25 et seq,) and to authorize coverage for ail the employees and their dependents thereunder in accor-
dance with the statute and regulations adopted by the State Heallh Benefits Commission.
2, A. )i{We elect to participate in the SHBP Employee Prescription Drug Plan defined by N,J,SA 52:14-17,25 et seq. and author-
ize coverage for all employees and their dependents in accordance with the statute and regulations adopted by the State Health
Benefits Commission.
B. 0 We will be maintaining
as our prescription drug plan.'
Name of Plan
C, 0 We will not have a stand-alone prescription drug plan and understand that prescription drug coverage will be provided by
the Health Plan,
3, A. 0 We elect to participate in the SHBP Employee Dental Plans defined by N,J.SA 52:14-17,25 et seq. and authorize cover-
age for all employees and their dependents in accordance with the statute and regulations adopted by the State Health Benefits
Commission.
B. )2<we will be maintaining
HartZel n Dv~ \
as our dental plan.'
Name of Plan
C. 0 We will not have a dental plan.
4. We elect ;) ~ 2 hours per week (average) as the minimum requirement for full time status in accordance with N,JAC,
17:9-4.6,
5. As a participating employer we will remit to the State Treasury all charges due on account of employee and dependent coverage and
periodic charges in accor.<iance with the requirements of the statute and the ruies and regulations duly promulgated thereunder,
6. We hereby appoint _
to act as Certifying Officer in the administration of this progra-m.-
Namerrrtle
7. This resolution shall take effect immediately and coverage shall be effective as of CJc +o\:'e.r I, :;l 003
or as soon thereafter as it may be ,effectuated pursua~t to the statutes and regulations, Oale
1 If not electing prescription drug coverage and/or dental plan participation through the SHBp, attach copies of current
prescription drug and dental plan contracts.
2 May not be less than 20 hours.
I hereby certify that the foregoing is a true and correct
copy of a resolution duly adopted by the;
Ro('ou,<j '" 00 Ccvr-teve.J-
Corporate Nama 01 Employer
on the liU6 day of if, J.:J ' 202Z
r~~ {/<V 0 /S.v~~
Signature
Number of Employees
Co 1 COO~ AveV\\J,,-e,
CO.\!' ~tfer-
City
(732-)
Area Code
Street Address
N,-Y.
Stale
5'11 - 3800
0700e
ZIP Code
Telephone
A~~iQtRnt ~lnirirRl r.lpr~
OlflclalTllle
Employer's Slale Sodal Security Identification Number
BELLINO - Yes
COWN - Yes
DIAZ - Yes
KRUM -
NAPLES
SITARZ
Yes
- _Absent
- Yes
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