The form has Section A, Access to a Qualified Health Plan, B, Least Expensive Plan, C, Employee Not Enrolled in Health Plan, D, Employee's Health Plan Information, and Section E, Signature.
Health insurance: does your company offer health insurance? If no, skip to section E, sign and return the form.
Section B: do not include the cost of dental, vision or other coverage if it is not included in the medical insurance premium amount.
Section C: has this employee or any family member dropped or reduced coverage in the last 90 days?
| Question | Answer |
|---|---|
| Form Name | DHHS 116M |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 82 |
| Avg. time to fill out | 14 min |
| Edition | Rev 03/2026 |
| Issuing agency | State of Utah Department of Health and Human Services |
| Where to send | Department of Workforce Services, PO Box 143245, SLC, UT 84114-3245; fax 1-801-526-9500 or toll-free fax 1-877-313-4717 |
| Other names | DHHS 116M, 116M, Form 116M, Utah 116M, Utah form 116M, Employer's Health Insurance Information |
| Official source | DHHS 116M (Rev 03/2026), State of Utah Department of Health and Human Services |
Form 116M isn’t the one you’re looking for?