Form 116m 2026

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The document is a form from the State of Utah's Department of Health, titled 'Employer's Health Insurance Information.' It is designed for employers to provide details about health insurance offerings for their employees. The form requires information on whether the company offers health insurance, enrollment periods, coverage specifics, and costs associated with various health plans. It also includes sections for employees not enrolled in a plan and requires signatures for submission.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the employee’s name, SSN (optional), and employer name in the designated fields.
Answer whether your company offers health insurance. If 'No', proceed to Section E.
Fill in the enrollment period start date and confirm if your company offers a qualified health plan by checking the appropriate boxes.
In Section B, complete the chart detailing the least expensive plan for each coverage type, including monthly premiums and deductibles.
If applicable, provide information about any existing health plans in Section D, including names of enrolled individuals and policy details.
Finally, sign and date the form in Section E before submitting it as instructed.

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