CMS-10439 Appendix B SHOP Employer Application

Small Business Health
Options Program (SHOP)
Health coverage application for employers
The SHOP Health Insurance Marketplace offers a new way for small employers to offer health insurance to
employees. The SHOP is open to all small business owners. It should take about 15 minutes to complete
this application for eligibility.

THINGS TO KNOW

✔

Who can use this
application?

• Employers who cannot apply online.
• Employers not working with a broker.

Is my business
eligible for the
SHOP?

Your business or organization must:
• Have a primary business address within the state where you’re
buying coverage,
• Have at least one common-law employee,
• Have 50 or fewer full-time equivalent (FTE) employees,* and
• Offer coverage through the SHOP to all full-time employees

Apply faster
online

• Visit HealthCare.gov to apply for SHOP online.
• Your coverage start date will be the first of the month at least
2 full months from the date the application is mailed. If you need
coverage sooner, apply online.

Get help

• 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
• Contact a broker: Visit HealthCare.gov or call
1-800-XXX-XXXX

What happens
next?

You’ll send this form and your employees’ completed, signed
applications to the address on page 3. You’ll hear back from
us within 1–2 weeks. We’ll let you know if you’re eligible to buy
insurance for your small business and give you the information you
need to compare cost and coverage options, select a plan, and
complete the enrollment process.

* Most states require 50 or fewer FTEs for the SHOP. To be eligible in some states, a business or organization can have 100 or fewer FTEs.
Starting in 2016, all businesses and organizations with 100 or fewer FTEs will be eligible for the SHOP.

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 your business or organization is eligible
for the SHOP and, if eligible, to facilitate enrollment.

STEP 1

Tell us about the employer offering coverage.

Employers must be located within the same state they’re buying health coverage and must offer coverage to all full-time
employees (those working on average 30+ hours per week).
* NOTE: If you’re using a broker to apply, you must apply online.
1. Employer name

2. Federal Employer Identification Number (EIN)

3. Doing business as
4. Employer type Private sector (profit & non-profit) Church/church affiliated State/local government Foreign government
Tribal government and tribally-owned or sponsored organizations and businesses
5. Primary business address
6. City

7. State

10. How many full-time equivalent employees?

STEP 2

11.

8. ZIP code

9. County

Yes, I’m offering health coverage to all full-time employees.

Tell us who to contact about this application.

Primary contact
1. First name, Middle name, Last name, & Suffix
2. Title
3. Mailing address (if different from primary business address above)
4. City

5. State

8. Phone number Work Home Cell

7. County

9. Other phone number Work Home Cell

( ) –
10. Fax number

6. ZIP code

( ) –

11. Email address

( ) –
12. Notices and monthly invoices will be sent electronically. This person must visit HealthCare.gov and create an online account to
receive electronic notices and invoices. Check here if this person also wants to get paper notices by mail.
13. Preferred spoken or written language (if not English)

Secondary contact (optional)
14. First name, Middle name, Last name, & Suffix
15. Title
16. Mailing address (if different from business address)
17. City

18. State

21. Phone number Work Home Cell

( ) –
23. Fax number

19. ZIP code

20. County

22. Other phone number Work Home Cell

( ) –

24. Email address

( ) –
NEED HELP WITH YOUR APPLICATION? Contact a 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 3

STEP 3

OPTIONAL
List all employees who’ll get an offer of coverage even if they may not enroll.

You must include all full-time employees (30+ hours)
Employee first name, middle name,
last name, & suffix

Date of birth
(mm/dd/yyyy)

Social Security number/
Tax ID Number

Email address

Employment
status*

Date of hire
(mm/dd/yyyy)

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

*Enter employment status: full time, part time, owner/business partner, spouse of owner, COBRA, or retired

Attach more sheets as necessary.

Page 2 of 3

STEP 4

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 my business or organization is eligible, this information will
be used to facilitate enrollment.
• I know that I must tell the SHOP if anything changes (and is different than) what I wrote on this
application. I can visit HealthCare.gov or call 1-800-XXX-XXXX to report changes.
• I have consent from everyone I’ll list on the application to include their personally identifiable
information, like dates of birth, Social Security numbers, addresses, and phone numbers.
• 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 5

Mail the completed application & your employee applications.

Mail your completed application, including all employee applications to:

Health Insurance
1005 XYZ Drive
Washington, DC 20005
You’ll hear back from us within 1–2 weeks. We’ll let you know if you’re eligible to buy coverage for your small
business, and provide you with the information you need to compare cost and coverage options, select a
plan, and complete the enrollment process.

*

NOTE: If you’re using a broker, you must apply online.

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
a broker, or call 1-800-XXX-XXXX.
Para obtener una copia de este formulario en Español, llame 1-800-XXX-XXXX.
Page 3 of 3