Get Employer Provided Health Coverage Informational Reporting ...

Filling out the Employer Provided Health Coverage Informational Reporting form can seem daunting. This guide provides step-by-step instructions to help you navigate the process online with ease and confidence.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the necessary platform.
2. Begin by entering your personal information. This includes your full name, social security number, date of birth, mailing address, marital status, gender, job title, phone number, and email address in the designated fields.
3. Indicate the reason for change in your employment status by selecting from the options provided, such as late enrollment or a qualifying event.
4. Select your current enrollment status and specify the enrollment status you are requesting, choosing from options like employee only, two-party, or family.
5. If you are adding or canceling coverage, indicate your selections for medical, dental, vision, and any additional life coverage by checking the relevant boxes.
6. Provide details for any dependents by filling out their names, social security numbers, dates of birth, and genders as required.
7. Review and complete the employee authorization statement, confirming your consent to deductions for the coverage you have selected.
8. Sign and date the form at the bottom. Ensure that you return this form to your employee benefits office no later than 31 days from your qualifying event.
9. After submission, keep an eye out for a confirmation of enrollment notice. If necessary, address any discrepancies by contacting your employee benefits office.

Take the first step in managing your health coverage — complete the Employer Provided Health Coverage Informational Reporting form online today.