Covered Individuals

Part III - Covered Individuals

First, check the box to indicate whether or not the employer is completing Part III.

Line 17 to 22: Covered Individuals

Complete Part III only if your employee enrolled in the employer-sponsored, self-insured health coverage you offered.
For Part III, coverage under a multiemployer plan is not included in employer-sponsored, self-insured coverage.

Then, complete the information for each individual covered under the employer's self-insured health plan who is not the employee (spouse, dependent(s)). You'll need to enter the name, SSN or DOB, and the months covered for each of these individuals.