Employer Sponsored Health Insurance Form

ADVERTISEMENT

Health Insurance Processing Center
PO Box 4405, Taunton, MA 02780 Fax: (617) 887-8770
Employer-sponsored Health Insurance Form
1. Please fill out the first section of this form.
2. Ask your employer to fill out the rest.
3. Mail or fax the form to the Health Insurance Processing Center.
The address is at the top of this page. You must send the form
by the date listed on the verification request.
EMPLOYEE
Who is the employee?
Employee name (first, middle, last):
Member ID:
_ _ _ – _ _ – _ _ _ _
Social Security number:
The employer should fill out the rest of this form.
EMPLOYER
Company name:
_ _ – _ _ _ _ _ _ _
Phone:
Employer Identification Number (EIN):
Street address:
City:
State:
ZIP code:
Name of person filling out this section (first and last):
Your title:
Your phone:
Your email:
With the health plan that this employer offers (check one):
This employee does not qualify You can skip the next questions, and sign and date this form.
This employee qualifies
This employee will qualify on (month, day, year):
__________________________________________________________________________________________________________
If this employee qualifies or will qualify for coverage:
What is the lowest cost individual plan this employee could enroll in?
_____________________________________________________________________________
How much would the employee pay in premiums? $
_______________________________________
How often?
Each week
Once a month
Twice a month
Once a year
No plans meet the “minimum value” standard.
Minimum value means that the health insurance plan pays at least 60% of the total
costs of the average enrollee. The insurance company will know this information.
Employer signature:
Date:
Visit or call 1-877 MA ENROLL (1-877-623-6765).
Questions?
(TTY: 1-877-623-7773} Monday to Friday, 8 a.m. to 6 p.m. The call is free.

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go