W 9 rev Form 2013-2024

W 9 rev 2024 Form: What You Should Know

Do not use Form W-9 or any other TIN from a prior tax year. (If required) Check all () boxes. Select check boxes to indicate the type of health insurance(s) you ▷. Check boxes only if required by federal law or Regulation (1) “I” Insurance (C or E) and/or Medicare Advantage Policy (M or M+) ▷. Check the box if the insurance company or provider you are applying for is a “I” insurance carrier. (see regulations, sections 6021(a) and (e) of the Internal Revenue Code) (E) Medicare Advantage Plan Medicare Advantage Plan is a group or employee benefit plan that permits some plan participants to enroll in health coverage by paying monthly premium and out-of-pocket expenses. Medicare Advantage Plan is also known as Premium Support. Medicare Advantage Plans are available only to eligible plan participants and their spouses and any dependents that are eligible for Medicare or Medicare Advantage. (Please see Regulation 45 CFR Part 1505-2. For more information on Medicare Advantage Plans, please refer to the Medicare Advantage Plan Fact Sheet). (2) “E” or Premium Support Insurance (P or C) ▷. Check box if you intend to use the “E” or Premium Support (P) insurance. See Regulations section 6022.3 for more information on Premium Support Plans and the Medicare Advantage Plans. If you select P, see section 1304 for more information on eligibility. If you select C or S and if you want to apply at a site, see Registration or enrollment forms, for details on what forms to use if the information does not appear directly on the site. Enter the TIN in the appropriate box. The TIN provided must match the name given on the “Name” line. Note: Check the appropriate box in the line (1) “I” Insurance (C or E) and/or Medicare Advantage Policy (M or M+) ▷. Click the “Submit” button. Note: If you select P or C, you must also select the plan enrollment form in the corresponding box. Note: If the TIN you enter doesn't match, the TIN on the form will be returned. If you select C or S and if you want to apply at a site, see Registration or enrollment forms, for details on what forms to use if the information does not appear directly on the site.

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