About Your Employer-Sponsored Health Coverage

We need to ask you a few questions about the coverage your employer is offering. It's important that you enter the information exactly as it appears in the guide provided by your employer - Using Plan Match for your Employer Coverage - to get accurate plan information and pricing.

When did/will your employer's plan begin?

(Use the employer's effective date of coverage shown on your Employee Instruction Letter)

Date: / 01 /

What is your employer's contribution towards your medical premiums?

Who does your employer offer coverage to?

Employer contribution

Employee:

Employee Coverage

Spouse:

Spouse Coverage

Domestic Partner:

Domestic PartnerCoverage

Children under 26:

Children Coverage