Employer coverage: Fill out & sign online

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Click ‘Get Form’ to open the doh 4450 in the editor.
Begin by entering the employee's last name, first name, and address in the designated fields.
Indicate whether the employee is currently enrolled in health insurance coverage through your company by selecting 'YES' or 'NO'. If 'YES', complete Section A; if 'NO', proceed to Section B.
In Section A, provide details such as Employer Name, Phone Number, Insurance Carrier/Union Name, Group Number, and Carrier Address. Ensure all fields are filled accurately.
List the coverage dates and type (Family/Couple/Individual), along with the monthly employee premium amount. Include any standard deductibles, co-insurance, and co-payments.
Check all applicable benefits under Scope of Benefits and attach a plan summary as required.
If completing Section B, check the appropriate box regarding health insurance availability and provide any necessary explanations.
Finally, review all entered information for accuracy before saving or exporting your completed form for submission.

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