Use this tool to gather answers about any employer health coverage that you’re eligible for (even if it’s from another person’s job, like a parent or spouse). You’ll need this information even if you don’t accept the employer insurance you’re eligible for. Write your name and Social Security number in boxes 1 t you’re eligible for. EMPLOYEE Information The employee | 1. Employee name (First, Middle, Last) | 2. Social Security Number | | - | - | | EMPLOYER Information | | Ask the employer for this information. | | 3. Employer Name | | Life is Good | 04 - 3394786 | | 5. Employer address (the Marketplace will send notices to this address) | 6. Employer phone number | | 48 Friars Drive | | (603) 594 | - 0278 | | 7. City | 8. State | 9. ZIP code | | Hudson | NH | 03051 | | 10. Who can we contact about employee health coverage at this job? | | 12. Email address | | ( | ) | - | Yes (Continue) 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue) No (STOP and return this form to employee) Tell us about the health plan offered by this employer. Yes. Which people? Spouse Dependent(s) No (Go to question 14) Yes (Go to question 15) No (STOP and return form to employee) 15. For the lowest-cost plan that meets the minimum value standard* (don’t include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn’t receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Quarterly Yearly 16. What change will the employer make for the new plan year? a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Quarterly Yearly