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The document is a health insurance information form (DOH/Form 116M) that must be completed by an employer or HR representative for each employed household member. It collects details about the employee's health insurance coverage, eligibility, and costs associated with the employer's health plans. The form includes sections for general employee and employer information, questions regarding health insurance offerings, and requires a signature from a representative certifying the accuracy of the provided information.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (193 Votes)
2019	4.3 Satisfied (46 Votes)
2014	4.2 Satisfied (57 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the income limit to qualify for Medicaid in Utah?

Check Your Eligibility Household SizeYou may qualify for Medicaid if you make less than: 1 $19,392/year 2 $26,232/year 3 $33,072/year 4 $36,912/year6 more rows

Do I have to accept my employers health insurance?

The short answer is no, you dont have to enroll in your employers health insurance coverage. That said, if job-based health insurance is offered and affordable, it is usually a good option to cover your familys medical needs.

What is the employer health insurance form?

Form 1095-C identifies the employee and employer, months the employee was eligible for coverage, and the cost of the cheapest monthly premium under the plan.

What is an example of proof of health insurance?

A current member ID card. A letter from your insurance company verifying coverage, sometimes called a certificate of coverage. Explanation of benefits. Form 1095-A if you are covered by a plan purchased through the health insurance marketplace.

What is the 116M form?

The DOH Form 116M is a detailed document from the State of Utah Department of Health, designed for employers to provide comprehensive information about the health insurance options available to their employees.