Marketplace Application Checklist

When you apply for coverage in the Health Insurance Marketplace, you’ll need to provide some

information about you and your household, including income, any insurance you currently have, and

some additional items.

Use the checklist below to help you gather what you need to apply for coverage. Open enrollment

starts October 1, 2013 for coverage starting as early as January 1, 2014. Open enrollment ends

March 31, 2014.

Social Security Numbers (or document numbers for legal immigrants)

Employer and income information for every member of your

household who needs coverage (for example, from pay stubs or W-2

forms—Wage and Tax Statements)

Policy numbers for any current health insurance plans covering

members of your household

A completed Employer Coverage Tool (see page 2 of this checklist)

for every job-based plan you or someone in your household is eligible

for. (You’ll need to fill out this form even for coverage you’re eligible

for but don’t enroll in.)

Stay up-to-date about the Marketplace. Visit to get email or text

updates that will help you get ready to apply.Form Approved EMPLOYER COVERAGE TOOL OMB No. 0938-1191

Use this tool to gather answers about any employer health coverage that you’re eligible for (even if it’s from another person’s

job, like a parent or spouse). You’ll need this information even if you don’t accept the employer insurance you’re eligible for.



EMPLOYEE information

The employee needs to fill out this section.

1. Employee name (First, Middle, Last) 2. Social Security Number

– –


EMPLOYER information

Ask the employer for this information.

3. Employer name 4. Employer Identification Number (EIN)

5. Employer address (the Marketplace will send notices to this 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 from above)

( ) –

12. Email address


Yes (Go to question 13a.)

13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for

coverage? (mm/dd/yyyy) (Go to next question)

No (STOP and return this form to employee)

Tell us about the health plan offered by this employer.

Does the employer offer a health plan that covers an employee’s spouse or dependent?

Yes. Which people? Spouse Dependent(s)


(Go to question 14)

14. Does the employer offer a health plan that meets the minimum value standard*?

Yes (Go to question 15) No (STOP and return this form to employee)

15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans): If the

employer has wellness programs, provide the premium that the employee would pay if he/she received the maximum discount for any

tobacco cessation programs, and didn’t receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan? $

b. How often? Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly (Go to next question)

If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and return

this form to employee.

16. What change will the employer make for the new plan year?

Employer won’t offer health coverage

Employer will start offering health coverage to employees or change the premium for the lowest-cost plan that meets the minimum

value standard* and is available to the employee only. (Premium should reflect the discount for wellness programs. See question 15.)

a. How much will the employee have to pay in premiums for that plan? $

b. How often? Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly

Date of change (mm/dd/yyyy):

*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than

60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986).

NEED HELP WITH YOUR APPLICATION? Visit or call the Marketplace Call Center at 1-800-318-2596. Para obtener una

copia de este formulario en Español, llame 1-800-318-2596. If you need help in a language other than English, call 1-800-318-2596 and tell the

customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.

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