Omb no 1210 0149-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Part A: General Information. Review the introduction about the Health Insurance Marketplace and its benefits.
3. Proceed to Part B: Information About Health Coverage Offered by Your Employer. Fill in your employer's name, EIN, address, and contact details accurately.
4. Indicate whether your employer offers health coverage to all or some employees and specify eligible dependents if applicable.
5. Answer questions regarding eligibility for coverage and whether the employer’s plan meets the minimum value standard.
6. Complete any optional sections that provide additional information about your employer's health plan offerings.

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