DOH Form 116M State of Utah
02/21
Department of Health
EMPLOYER'S HEALTH INSURANCE INFORMATION
Complete this form for each employed household member. Your employer‘s Human Resources
representative or department who manages employee benefits must complete it.
Employee’s Name:
(first, m.i., last) D02921900040102
SSN (optional) or DOB: eREP Case #:
Employer Name: EIN #:
Yes No 1. Does your company offer health insurance?
If no, skip to section E, sign, and return the form.
2. When does your company's enrollment period begin? (mm/dd/yy)
Section A – Access to a Qualified Health Plan:
Yes No 3. Does your company offer any health plan that meets all of the following?
• The network deductible is $4,000 or less per person
• The plan pays at least 70% of an inpatient stay after employee meets in-network deductible
• The plan covers physician's visits, inpatient and outpatient hospital care, prescription drugs, laboratory services,
preventative and wellness services, pregnancy, and childbirth
• Employer pays at least 50% of the employee's premium
• Lifetime maximum benefit is $1,000,000 or more, or the plan has no maximum
Check one: 4. How do those plans cover abortion services? This can typically be found in the maternity/pregnancy or exclusion
sections of your policy.
Does not cover abortion in any circumstances
Plan covers elective abortion
Covers abortion only in the case where the life of the mother would be endangered if the fetus were carried to
term, or in the case of incest or rape (plan lists this exact language)
Other, or if multiple plans offer differing coverages, please describe:
Section B - Least Expensive Plan
Complete the chart below for the plan that would cost the employee the least. Do not include the cost of dental, vision or other coverage
if it is not included in the medical insurance premium amount.
Monthly Premium Yearly Health Plan Deductible
Employee’s Portion Company’s Portion Individual Amount $
Employee $ $ Family Amount $
Employee + Spouse $
Employee + Child $
Family $
Yes No 5. Is this health insurance plan a state employee benefit plan?
If the employee is enrolled in health insurance skip to section D
Section C – Employee Not Enrolled in Health Plan:
Yes No 6. Is this employee eligible to enroll in a health insurance plan?
If no, why not?
Yes No 7. Was the employee eligible to enroll in the last open enrollment period?
Yes No 8. Has this employee or any family member dropped or reduced coverage in the last 90 days?
If yes, name(s):
If yes, when did coverage end/change? (mm/dd/yy)
Section D - Employee's Health Plan Information:
Yes No 9. Is this employee or any family member enrolled in any insurance plan offered?
If no, skip to section E
If yes, name(s) of person(s) enrolled:
When did coverage begin? (mm/dd/yy)
D02921900040202
Insurance company and plan name:
Policy number: Group number:
What is the check date for the first premium deduction?
Yes No 10. Does the employee's chosen health plan meet all of the following?
• The network deductible is $4,000 or less per person
• The plan pays at least 70% of an inpatient stay after employee meets in-network deductible
• The plan covers physician's visits, inpatient and outpatient hospital care, prescription drugs, laboratory services,
preventative and wellness services, pregnancy, and childbirth
• Employer pays at least 50% of the employee's premium
• Lifetime maximum is $1,000,000 or more, or the plan has no maximum
Check one: 11. How does the plan cover abortion services? This can typically be found in the maternity/pregnancy or exclusion sections of
your policy
Does not cover abortion in any circumstances
Plan covers elective abortion
Covers abortion only in the case where the life of the mother would be endangered if the fetus were carried to
term, or in the case of incest or rape (plan lists this exact language)
Other, please describe:
12. What is the monthly premium cost of this plan for a single employee, not including any family members?
This plan's monthly premium cost for just a single employee
Employee Cost Employer Cost
$ $
13. Complete this chart for the benefits the employee is enrolled in. Fill out all applicable boxes
Premium deducted from this employee's check:
How often is the premium deducted?
Weekly Every 2 Weeks Twice a month Monthly Other (Specify:)
Medical (Required) Dental (Optional) Vision (Optional)
Employee $ $ $
Employee + Spouse $ $ $
Employee + Child $ $ $
Family $ $ $
Yearly Health Plan Deductible
Individual Amount $
Family Amount $
14. Please list any children who have dental coverage
Section E - Signature:
Name (please print): Title:
Phone #: Email Address:
Signature Date:
Please Return Completed Form To:
Department of Workforce Services, PO Box 143245, SLC, UT 84114-3245
Fax: 1-801-526-9500 Toll-Free Fax: 1-877-313-4717
