LEGAL NOTICES
PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to completean application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplaceapplication.
4. Employer Identification Number (EIN)
3. Employer name
5. Employer address
6. Employer phone number
7.City
8. State
9. ZIP code
10. Who can we contact about employee health coverage at this job?
11. Phone number (if different fromabove)
12. Emailaddress
Here is some basic information about health coverage offered bythis employer: ● As your employer, we offer a health planto: □ All employees. Eligible employeesare: □ Some employees. Eligible employees are:
● With respect todependents: □
We do offer coverage. Eligible dependents are: □ We do not offercoverage.
□ If checked, this coverage meets the minimum value standard, and the cost of this coverage to you isintended to be affordable, based on employeewages.
^^ Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid – year, or if you have other income losses, you may still qualify for a premium discount. If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthlypremiums.
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PRIVATE PREP BENEFITS GUIDE
LEGAL NOTICES
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