Form CMS-10438 Appendix_B-SHOP_Employee_Application

Small Business Health
Options Program (SHOP)
Health coverage application for employees

THINGS TO KNOW

Use this application to see if you’re eligible to get SHOP health coverage from your employer. It should
take about 10 minutes to complete this application.

Go online

Visit HealthCare.gov. You’ll be able to see details about SHOP
coverage in the Health Insurance Marketplace.

Get help

Ask your employer who to call with questions.
• Online: HealthCare.gov
• Phone: Call our Help Center at 1-800-XXX-XXXX
• En Español: Llame a nuestro centro de ayuda gratis al
1-800-XXX-XXXX

What happens
next?

You’ll return your completed, signed application to your
employer. Your employer will send us your completed, signed
application. We’ll contact you with information about how to
start a SHOP account, find out about costs and coverage, and
enroll in a plan.

Alternatives

If your share of the cost of employee-only coverage is more
than 9.5% of your household income, you may able to get help
paying for coverage through the individual Health Insurance
Marketplace. Visit HealthCare.gov to learn more.

Your information is private.
• We’ll keep your information private as required by law.
• Your answers on this form will only be used to see if you qualify for health coverage in the SHOP
and to help you enroll.

Who is your employer?
Employer name & address

Employer phone number

(

)

–

Get started with your application below.

Not interested in SHOP health coverage?
If you don’t want SHOP health coverage from your employer, skip to Step 3 on page 3.

STEP 1

I’m interested in SHOP coverage from this employer.
Information about you, the employee.

1. First name, Middle name, Last name, & Suffix
2. Social Security number/Tax ID Number

3. Date of birth (mm/dd/yyyy)

4. Sex
Male

5. Home address (leave blank if you don’t have one)
7. City

8. State

9. ZIP code

10. County

11. Mailing address (if different from home address)
13. City

Female

6. Apartment or suite
number

12. Apartment or suite
number
14. State

15. ZIP code

16. County

17. Email address
18. Phone number

(

)

Cell

Home

Work

19. Other phone number

–

(

)

Cell

Home

Work

–

20. Notices will be sent electronically. You must go to HealthCare.gov and create an online account to receive electronic notices.
Check here if you also want to get paper notices by mail.
21. Preferred spoken or written language (if not English)
22. If Hispanic/Latino, ethnicity (OPTIONAL—Check all that apply.)
Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

Other

23. Race (OPTIONAL—Check all that apply.)
White
Black or African
American

American Indian or
Alaska Native
Asian Indian
Chinese

Filipino
Japanese
Korean

Vietnamese
Other Asian
Native Hawaiian

Guamanian or Chamorro
Samoan
Other Pacific Islander
Other

24. If you’re American Indian or Alaska Native, tell us the state and the name of your federally-recognized tribe

NEED HELP WITH YOUR APPLICATION? Contact your employer’s broker with questions, visit HealthCare.gov, or
call us at 1-800-XXX-XXXX. TTY users should call 1-800-XXX-XXXX. Para obtener una copia de este formulario en
Español, llame 1-800-XXX-XXXX.

Page 1 of 2

STEP 2

Read & sign this application.

• I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the
questions to the best of my knowledge. I know that I may be subject to penalties under federal law if I
intentionally provide false or untrue information.
• I know that my information on this form will only be used to determine eligibility for health coverage and will
be kept private as required by law. If I’m eligible, it will be used to help me enroll.
• I know that I must tell the SHOP if anything changes (and is different than) what I wrote on this application. I can
call my employer’s agent or broker, visit HealthCare.gov, or call 1-800-XXX-XXXX to report changes.
• I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex,
age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by visiting
www.hhs.gov/ocr/office/file.
Signature

Date (mm/dd/yyyy)

STEP 3

If you don’t want SHOP coverage from this employer.

I don’t want health coverage from this employer. If this employer offers health coverage for my
dependents, I decline that offer of coverage, too.
Answer these questions:
Do you have another source of health coverage?
If yes, what type?
Individual private health insurance
Insurance from another job
Insurance through another person’s job

Yes

No

Medicare
Medicaid
Indian Health Service

TRICARE
VA health care programs

If this employer offers dental coverage, I don’t want that coverage. If this employer offers dental for
my dependents, I decline that offer of coverage, too.
Employee name
Signature

Date (mm/dd/yyyy)

STEP 4

Return your completed, signed application to your employer.

Your employer will send us your application, and you’ll hear back from us with details about how to start a SHOP account,
find out about costs and coverage, and enroll in a plan.
If you want to register to vote, you can complete a voter registration form at XXXXX.gov.
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays
a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete
this information collection is estimated to average [Insert Time (hours or minutes)] per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Need help?
If you have questions about this application or need help completing it, contact your employer,
your employer’s agents or brokers, visit HealthCare.gov, or call us at 1-800-XXX-XXXX.
Para obtener una copia de este formulario en Español, llame 1-800-XXX-XXXX.
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