Get Hc 5 2017 Form

Filling out the Hc 5 2017 Form online can help you effectively communicate your health care coverage preferences to your employer. This guide provides a step-by-step approach to ensure that you complete the form accurately and efficiently.

Follow the steps to complete the Hc 5 2017 form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in your employer's name in the designated field, followed by their Department of Labor account number. Ensure accuracy in this section as it identifies your employer for the purposes of the form.
3. Next, provide your employer's address and phone number in the specified fields. This information is crucial for correspondence concerning your health care coverage.
4. In the section indicating if you are working for two or more employers, check the appropriate box based on your situation. This will determine if your selected employer is your principal or secondary employer.
5. If you are claiming an exemption, mark the corresponding checkbox based on the eligibility criteria provided, such as being covered under a federally established health insurance plan or being a recipient of public assistance.
6. If you are waiving coverage from your employer’s health care plan, provide the required information regarding the alternative health care plan you have obtained, including the name of the plan and the health care plan contractor.
7. Should any changes in your coverage needs occur, remember to check the box indicating that the previously stated exemption or waiver is no longer applicable. This signals to your employer that you require health care coverage.
8. Enter the requested effective date of coverage in the designated area. This date is pivotal for determining when your health care coverage will commence.
9. After completing all necessary fields, ensure you print your name, sign the form, and include your address and phone number. This confirms your identity and agreement to the selections made.
10. Finally, review the entire form for accuracy, and once satisfied, you can save changes, download, print, or share the completed form with your employer.

Complete your Hc 5 2017 form online today and ensure your health care preferences are communicated.