Employee Application Form

Fillable (Save and Print)	Employer Subsidy Application Form	Part 1A Supplemental Form
Blank Form - Print and Fill out	Employer Subsidy Application Form	Part 1A Supplemental Form

Employee Application Form

Step 1 - Contact your health insurance broker/agent

Employers should first select a health insurance broker/agent who will assist with the subsidy application process.

Step 2 - Complete the application forms

The employer will have to provide the required information in an application for health insurance plus additional information about the wages of each full-time employee. Based on that information, the broker/agent will be able to calculate the total subsidy per employee for different health plans as well as the total cost to the employer after the subsidy is applied.

Step 3 - Select a health benefit plan ( Get Quote and Plan selection from Broker)

The employer and broker/agent will work together to select a small employer health benefit plan that includes a wellness benefit. A wellness benefit must be included within the health plan in order for the plan to qualify for the subsidy.

Step 4 - Determine Employer Contribution - Our Brokers will help you figure this out. (Contact Us)

The employer will determine the employer contribution to the employees' premium. If the health plan includes a Health Savings Account, the employer also determines the amount of the employer contribution. The total subsidy is divided between an employer and the employee based on the contribution each makes toward the cost of coverage.

Step 5 - Establish a Section 125 Plan.

The employer must establish a Section 125 plan within 60 days of enrollment in the Health Insurance Partnership Program . The forms below give you more information on establishing a Section 125 Plan and the benefits thereof Aetna FSA ( Section 125) Set Up Request Form and Pricing Guide Aetna Flexible Spending Account - Information