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  • Ut Doh 116m 2019

Get Ut Doh 116m 2019-2025

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.

  1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
  2. 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.
  3. In the 'Who can we contact about employee health coverage' section, provide the contact person's name, phone number, and email address.
  4. 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.
  5. Proceed to the 'Employer's least expensive plan' section. Respond to the enrollment questions and provide details for the monthly premium and deductible information.
  6. In the 'Employee's health plan choice' section, fill out the insurance company and plan name, policy number, and answer all relevant questions.
  7. Complete the final sections about health plan premiums and benefits. Ensure that all questions are answered accurately.
  8. Sign and date the form in the signature section, identifying yourself as the Human Resource representative or health insurance contact person.
  9. 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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Fill UT DOH 116M

Date: Please Return Completed Form To: Department of Workforce Services, PO Box 143245, SLC, UT 84114-3245. Fax: 1- Toll-Free Fax: 1-. ATTACHMENT C. Employer's Health Insurance Information.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232