Application For Health Coverage & Help Paying Costs Page 11

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Form Approved

Appendix A

OMB No. 0938-1191

Health Coverage from Jobs

You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job, even if they

don’t accept the coverage. Attach a copy of this page for each job that offers coverage.

Tell us about the job that offers coverage.

Make a copy of this page and take it to the employer who offers coverage to help you answer these questions.

Employee information

1. Employee name (First, Middle, Last)

2. Employee Social Security Number (SSN)

Employer information

3. Employer/company name

4. Employer Identification Number (EIN)

5. Employer phone number

Now, enter the information of the person or department who manages employee benefits. We may contact this person if we

need more information:

6. Person or department we can contact about employee health coverage

7. Employer address (the Marketplace may send notices to this address)

8. City

9. State

10. ZIP code

11. Phone number (if different from above)

12. Email address

13. Is the employee currently eligible for coverage offered by this employer, or will the employee become eligible in the next 3 months?

YES (Continue)

NO (EMPLOYER: STOP and return this form to the employee.

EMPLOYEE: return to your application for Marketplace

a. If the employee isn’t eligible today, including as a result of a

coverage.)

waiting or probationary period, when will the employee be eligible

for coverage? (mm/dd/yyyy)

b. Does the employer offer a health plan that covers this employee’s spouse or dependent(s)?

YES. If yes, which people?

NO (Go to question 14.)

Spouse

Dependent(s)

List the names of anyone else in the employee’s household who’s eligible for coverage from this job.

Name

continued on the next page

NEED HELP WITH YOUR APPLICATION?

Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. If you need help in a

language other than English, call 1-800-318-2596 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.