QSEHRA Proof of Coverage and Annual Attestation

QSEHRA Proof of Coverage and Annual Attestation

Verify your health insurance coverage annually.
Employee Name

First NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance Company
Policy Holder Name
Coverage Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Coverage Type

Other
Employee Signature
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Attach proof of coverage (Insurance ID card, Marketplace enrollment confirmation, or Insurance invoice/coverage letter)

Cancelof
Should be Empty: