Get Small Employer Application

Filling out the Small Employer Application online is an important step for securing health coverage as a small employer. This guide will provide you with a clear, step-by-step approach to completing the application accurately and efficiently.

Follow the steps to complete your Small Employer Application online.

1. Click 'Get Form' button to acquire the application and open it in your preferred editor.
2. Begin with Section 1, which requires employer and employment information. Provide details such as the name of the employer, contact number, address, city, state, ZIP code, occupation, hours worked per week, and the date you started working.
3. In Section 2, indicate whether you are a new applicant and specify the requested effective date. Check any relevant reasons for changes in current enrollment, such as adding dependents due to life events like marriage or the birth of a child.
4. Proceed to Section 3 for applicant information. Fill out your first name, last name, mailing address, phone number, email address, marital status, date of birth, height, weight, and social security number.
5. In Section 4, list all eligible dependents you wish to enroll. Include their names, relationships to you, dates of birth, gender, height, weight, and social security numbers.
6. If applicable, complete Section 5 to waive coverage, indicating the reasons for declining the coverage, and provide signatures where necessary.
7. Complete Section 6A by answering medical questions related to health conditions for yourself and dependents. Be truthful and thorough as each response affects your application approval.
8. If you answered 'Yes' in Section 6A, fill out Section 6B with detailed medical information for those conditions.
9. In Section 7, provide information regarding any current or prior coverage, including carrier information and applicable dates.
10. Finally, in Sections 8, 9, and 10, affirm the accuracy of your responses and sign accordingly. Ensure that you understand the implications of the application before submission.
11. Once all sections are completed, you can save changes, download, print, or share the completed Small Employer Application for your records.

Start filling out your Small Employer Application online today to ensure your employees receive the best coverage available.