EMPLOYER: This form is ONLY to be completed by employees if you offer and pay a portion of a healthcare plan that provides hospital and physician services AND… 1) the employee is eligible to enroll in such plan but elects not to; OR… 2) the employee can potentially be excluded from such reporting as they may meet the Health Care Contribution reporting definitions as a “part-time” or “seasonal” employee.
EMPLOYEE: Please complete Section A or B, sign and date, and return form to your employer.
The purpose of this form is to obtain information regarding your health care coverage. The information certified
on this form will be used solely for the purposes of determining if your employer must pay Health Care
Contributions, as required by Act 191 of the 2006 Legislature, An Act Relating to Health Care Affordability for
Section A: Complete this section ONLY IF you are eligible to enroll in the Health Care plan your employer
offers, but have declined or refused such coverage. Please check the appropriate box.
Section B: Complete this section if you are NOT eligible to enroll in the Health Care plan your employer offers.
Section C: Complete this section if you are ELECTING to enroll in the Health Care plan your employer offers.
NOTE to Employee: If at some point within the next year your health care coverage changes, you areencouraged to complete another declaration.