Employer Response {3F010}

EMPLOYER RESPONSE If 1, 2, 3, 4, or 5 below applies, check the appropriate box and return this Part A to the Issuing Agency within 20 business days after the date of the Notice, or sooner if reasonable. NO OTHER ACTION IS NECESSARY. If 1 through 5 does not apply, complete item 7 and forward Part B to the appropriate Plan Administrator(s) within 20 business days after the date of the Notice, or sooner if reasonable. This includes any organization or labor union that provides group health care benefits to the employee. Check number 5 and return this Part A to the Issuing Agency if the Plan Administrator informs you that the child(ren) would be enrolled in or qualify(ies) for an option under the plan for which you have determined that the employee contribution exceeds the amount that may be withheld from the employee's income due to State or Federal withholding limitations and/or prioritization. You are required to respond to the Issuing Agency by returning this Employer Response regardless of whether you provide group health benefits or the employee named herein is no longer employed by your organization. Information for the Plan Administrator and the Employer Representative at the bottom of this section is required. [] [] [] 1. The employee named in this Notice has never been employed by this employer. 2. We, the employer, do not offer our employees the option of purchasing dependent or family health care coverage as a benefit of their employment. 3. The employee is among a class of employees (for example, part-time or non-union) that are not eligible for family health coverage under any group health plan maintained by the employer or to which the employer contributes. Do not check this box if the employee is only temporarily ineligible for health care coverage. 4. Health care coverage is not available because employee is no longer employed by the employer: Date of termination: _________________________________ Last known telephone number: _________________________ Last known address: _________________________________ New employer (if known): ____________________________ New employer telephone number: _______________________ New employer address: _______________________________ [] [] 5. State or Federal withholding limitations and/or prioritization prevent the withholding from the employee's income of the amount required to obtain coverage under the terms of the plan. 6. The participant is subject to a waiting period that expires ___________________ (more than 90 days from the date of receipt of this Notice), or has not completed a waiting period, which is determined by some measure other than the passage of time, such as the completion of a certain number of hours worked (describe here: _____________________________ _____________________). At the completion of the waiting period, the Plan Administrator will process the enrollment. 7. Employer forwarded Part B to Plan Administrator on ______________. MM/DD/YY [] [] CONTACT FOR QUESTIONS Plan Administrator Name: _______________________________ FaxNumber: ________________________ Contact Person: _______________________________________ Telephone Number: __________________ Employer Name: ______________________________________ Employer Representative Name/Title: _____________________ Employee Name: ______________________________________ Telephone Number: __________________ Federal EIN: ________________________ (If not provided on Page 1 of this Notice) Date: ______________________________ Employer Name: <F004> Employer Federal EIN: <F054> Non-Custodial Parent: <F024> <F025> <F026> Non-Custodial Parent SSN: <F022> Bar Code (with FSN): <F019> FS#: <F019> OAG Case Number: <F003> Cause Number: <F040> Page 3 of 5 Form 3F010 American LegalNet, Inc. www.FormsWorkFlow.com NMSN - Part A April 2014