36-10

HB-0169-0904 PLEASE COMPLETE AND COMPLY WITH THE FOLLOWING: A. Employer New Jersey State Health Benefits Program identification Number B. Type of funding method with the new contract: 1. Conventionally insured fully insured 2. Minimum premium 3. Administrative Services Only (ASO) 4. Other (please list) C. New Health Carrier __ Horizon Blue Cross Blue Shield D. New Prescription Drug Carrier GS POPS E. New Dental Plan Carrier F. Reason for termination of the State Program price G. In accordance with N.J.S.A. 18A:16-21 and 40A:10-25, you must file a copy of your new contract with the State Health Benefits Commission. Please submit a copy of the new contract with this completed resolution.