Rule 1910.28.Order for Earnings and Health Insurance Information. Form of Earnings Report. Form of Health Insurance Coverage Information.

Official Note: the information requested in the following report may be provided by an employer on its own form, for example, as a computer print out. (Caption) HEALTH INSURANCE COVERAGE REPORT This information must be completed and returned within 15 days. Failure to comply may result in issuance of a subpoena or other appropriate sanctions. Employee’s Name: Employee’s Social Security #: Does the employer make medical, dental, eye care, prescription or other insurance coverage available to the employee? Yes 䊐 No 䊐 Name the dependents covered under the employee’s insurance, and indicate which types of coverage they have through your company. Type of Coverage Hospital- Prescrip- Full Name SS # ization Medical Dental Eye tion Other 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 䊐 Provide the information indicated for each type of insurance which is available to the employee, whether or not any of the above-named dependents are covered at this time: Insurance company (provider): Group #: Plan #: Policy #: Effective coverage date: Type of coverage: Cost of coverage for dependents: Insurance company (provider): Group #: Plan #: Policy #: Effective coverage date: Type of coverage: Cost of coverage for dependents: Insurance company (provider): Group #: Plan #: Policy #: Effective coverage date: Type of coverage: Cost of coverage for dependents: Insurance company (provider): Group #: Plan #: Policy #: Effective coverage date: Type of coverage: Cost of coverage for dependents: If the above-named dependents are not currently covered by insurance, please state the earliest date coverage could be provided. PLEASE PROVIDE FORMS NECESSARY TO ADD DEPENDENTS, AS THE EMPLOYEE MAY BE ORDERED TO PROVIDE COVERAGE FOR THEM. I verify that the statements made in this Health Insurance Coverage information form are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. Date: Signature: Title: