116m form 2026

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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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Click ‘Get Form’ to open the 116m form in the editor.
Begin by filling in the 'Employee Information' section. Enter the employee's name and Social Security Number (SSN) accurately.
In the 'Employer Information' section, provide the employer's name, EIN, phone number, and address. Ensure all fields are completed to avoid delays.
Answer the questions regarding health insurance offerings. Select 'Yes' or 'No' for each question and provide additional details where required.
Complete the sections about health plan choices and premiums. Fill in any relevant information about deductibles and coverage options.
Finally, ensure that a representative from Human Resources signs and dates the form before submission.

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