Discover a sample of employee health insurance responsibility disclosure form and its contents.

For some time now, it has been a requirement for employees to fill the employee health insurance responsibility disclosure form. Employers are required to issue the form to employees who refuse to apply for health insurance offered by the organization or plans administered by the government through certain employment acts. What does the employee health insurance responsibility disclosure form entail?


Key components of the responsibility disclosure form

Purpose of the form

Right at the top of the document, you should include a paragraph explaining why the employee is required to fill the form. For instance, if the employee works in any state in the United States, it is important to fill the form if they have declined the health insurance cover, which the employer offers. Another reason why an employee may be required to fill the form is if they have refused to take Section 125 Cafeteria Plan.

Employer Details

The next section carries the details of the employer. They include their name, D/B/A, FEIN, physical address, and zip code. You also need to fill in details about whether you offered any health insurance plans to the employee. In the case of companies operating in any of the U.S states, your employee’s options include employer-sponsored health insurance cover and Section 125 Cafeteria Plan. If you had offered any cover, specify the least amount that you offered to the individual.

Employee information

This section should be filled by the employee. They should include their full names and titles. In addition, they should state if they accepted health insurance plan, which was offered by the employer or they purchased a cover through the Cafeteria Plan. The form also requires the employee to specify if they have other health insurance plans.

Affidavit of the employee

This clarifies that the employee confirms that the information provided in the form is true. It also demonstrates they understand that by not having any health cover, they are responsible for their medical costs.

Employee health insurance responsibility disclosure form sample

You are filling this for because you have declined to accept your employer’s health insurance plan and/or have refused to participate in the pre-tax purchasing plan as provided by Section 125 Cafeteria Plan.

Employer Name: […] FEIN: […]

D/B/A: […]

Employer Address: […]

City/State/Zip Code: […]

  1. Did you provide a “Section 125 Cafeteria Plan” to this employee?
  2. Did you provide employer-sponsored health cover to the employee?
  3. If you provided the employer-sponsored health insurance, what amount in dollars was the premium of the least plan?

Employee First Name: […] Initial of the Middle Name: […]

Last Name: […] Suffix: […]

  1. Did you accept your employer-sponsored health cover?
  2. Did you use the Section 125 Cafeteria Plan to purchase health insurance?
  3. Do you have another health cover?

Employee Affidavit

I confirm that the information offered herein is true to the best of my knowledge. I do understand that if I have no insurance cover, I will be responsible for my medical expenses.

Employee Signature/Date

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