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Click ‘Get Form’ to open the Employee Health Insurance Responsibility Disclosure Form in the editor.
Begin by filling out the employer section. Enter the Employer Name, FEIN, D/B/A (if applicable), and complete the Employer Address including city, state, and ZIP Code.
Respond to questions 1 and 2 by checking 'Yes' or 'No' regarding the offer of a Section 125 Cafeteria Plan and employer-sponsored health insurance.
If applicable, provide the dollar amount of the employee’s portion of the monthly premium for the least expensive individual health plan offered by your employer.
Next, move to the employee section. Fill in the Employee First Name, Middle Initial, Last Name, and Suffix if necessary.
Answer questions about accepting employer-sponsored health insurance and using a Section 125 Cafeteria Plan by selecting 'Yes', 'No', or 'None Offered'.
Indicate whether you have other health insurance by checking 'Yes' or 'No'.
Finally, sign and date the form in the designated area to affirm that all information is accurate.

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What is the employer responsibility for health insurance?

Employer mandate overview Employers must offer health insurance that is affordable and provides minimum value to 95% of their full-time employees and their children up to the end of the month in which they turn age 26, or be subject to penalties. This is known as the employer mandate.

Do I have to report employee paid health insurance on W-2?

The Affordable Care Act requires employers to report the cost of coverage under an employer-sponsored group health plan on an employees Form W-2, Wage and Tax Statement, in Box 12, using Code DD.

What is a proof of health insurance letter from an employer?

A proof of insurance letter is official documentation indicating that an individual possesses coverage under an insurance scheme. While it pertains to various policy types, its utmost significance to companies lies in health insurance.

Can my employer see what I do with my health insurance?

However, your employer cannot obtain information about you from your health care provider directly without your authorization, unless other laws require them to disclose it. However, if you work for a health plan or a covered health care provider, the Privacy Rule does not apply to your employment records.

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