DOH/Form 116M 05/2014 Case Employer s Health Insurance Information A l This form MUST be completed by your employer or your company s Human Resources representative. Any blanks left on this form may delay the process. l A form must be completed for each employed household member. You may copy this form* l If you have general questions about this form or the medical programs please call 1-866-435-7414. General Information Employee Information Employee name first m*i. last Employee SSN EIN Phone Address street apt. city state zip Who can we contact about employee health coverage at this job Contact Name Phone Email address oYes oNo 1. Does your company offer health insurance If no skip to section D. Sign and return the form* 2. Is your health insurance a state employee benefit plan 4. Is the employee eligible to enroll in any insurance plan offered If no please explain If yes when is/was the employee eligible to enroll mm/dd/yy If yes name s of person s enrolled 6. Has this employee or a....
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How to fill out the UT DOH 116M online
Completing the UT DOH 116M form is essential for providing accurate health insurance information for employees. This guide offers clear steps to ensure a smooth online submission process.
Follow the steps to fill out the UT DOH 116M with ease.
- Click ‘Get Form’ button to obtain the form and open it in the online editor.
- Begin by filling in the general information section. Include the employee's name and Social Security Number (SSN), as well as the employer's name, Employer Identification Number (EIN), phone number, and address.
- In the 'Who can we contact about employee health coverage' section, provide the contact person's name, phone number, and email address.
- Answer the questions from 1 to 8 regarding the availability and specifics of the health insurance. Make sure to provide any required explanations in the spaces provided.
- Proceed to the 'Employer's least expensive plan' section. Respond to the enrollment questions and provide details for the monthly premium and deductible information.
- In the 'Employee's health plan choice' section, fill out the insurance company and plan name, policy number, and answer all relevant questions.
- Complete the final sections about health plan premiums and benefits. Ensure that all questions are answered accurately.
- Sign and date the form in the signature section, identifying yourself as the Human Resource representative or health insurance contact person.
- Once all sections are completed, review the information for accuracy before submitting. You can save changes, download the form for your records, or print it for submission.
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