New Hire ACA Form

NEW HIRE ACA FORM

Employee Personal Information

Phone:    Email:

Date of Birth:    Employee ID (if assigned):

Position & Employment Details

Reporting Manager:    Start Date:

Employment History (Most Recent Employers)

Education

Graduation Date:

Professional References

ACA Coverage Offer & Election

Employer Offered Health Coverage: Yes No

Coverage Tier(s) Offered: Employee Only Employee + Spouse Employee + Children Family

Coverage Effective Date (if enrolled):    Waiting Period (if any):

Employer Certification of Coverage: This plan provides Minimum Essential Coverage (MEC)    Employer attests plan meets ACA affordability standard or applicable safe harbor

Employee Election

I elect to: Enroll in employer-sponsored coverage Decline coverage

Covered under other employer plan    Covered by Medicaid/CHIP    Cost is unaffordable    Other:

Dependent Enrollment

Dependent 1

DOB:    Relationship:

Dependent 2

DOB:    Relationship:

Dependent 3

DOB:    Relationship:

Legal Disclosures & Authorizations

At-Will Employment: I understand that my employment, if any, is at-will and either I or the employer may terminate the employment relationship at any time, with or without cause, unless a written agreement signed by authorized representatives states otherwise.

Equal Employment Opportunity: The employer is an equal opportunity employer. Employment decisions will be made without regard to factors protected by law.

Authorization to Verify: I authorize the employer and its agents to contact my prior employers, educational institutions, references, and any other third parties to obtain information relevant to my employment, including but not limited to dates of employment, positions held, performance, disciplinary records, and reasons for separation. I release all parties from liability for providing such information.

Background Checks and Drug Screening: I consent to any pre-employment background checks, motor vehicle record checks, and/or drug/alcohol screening that may be required as a condition of employment. I understand that a refusal to consent may preclude hiring.

Payroll Deduction Authorization: If I elect coverage that requires employee contributions, I authorize the employer to deduct the required employee premium contributions from my wages, on a pre-tax or after-tax basis as designated by the plan rules and applicable law.

Applicant Certification

I certify that all information provided on this form is true, correct, and complete to the best of my knowledge. I understand that any misrepresentation or omission of material facts may result in denial of benefits, discipline, or termination of employment. I agree to notify Human Resources promptly of any changes to the information provided on this form.

I further acknowledge receipt of the employer's summary of benefits and that I have been given the opportunity to ask questions regarding the plan and enrollment procedures where required.

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