Employer Application 

Insurance Partnership

Complete one application for each federal employer identification number (FEIN) 
or equivalent. 

Commonwealth of Massachusetts
Division of Medical Assistance

This application contains (check one): new information revised information

Effective date of new or revised information: /   /

Section 1 - Employer Information 

FEIN or equivalent:

Corporate address (legal entity)

Legal entity name 
Attn.
P.O. box (if applicable) 
Street address 
City 
State 
Zip
Telephone number 
( ) 
Fax number 
( )

Doing business as (DBA) If the business has more than one DBA address, attach a 
separate sheet with the other addresses.

DBA name 
Attn.
P.O. box (if applicable) 
Street address 
City 
State 
Zip
Telephone number 
( ) 
Fax number 
( )

Mailing address (if different)
Business name 
Attn.
P.O. box (if applicable) 
Street address 
City 
State 
Zip
Telephone number 
( ) 
Fax number 
( ) 

Business start date: /   /
Nature of business: 
Standard industrial code:
Number of full-time employees (who are scheduled to work 30 or more hours a 
week):

Number of employees who are eligible for health insurance through your business: 

over 




Section 2 - Insurance Information 

Please provide the information requested below for each policy tier of the 
health plan you offer. If you contribute different amounts based on employee 
type (for example, full-time vs. part-time, or union vs. non-union), specify in 
the last three columns of the chart the amount you contribute for each type 
using the following codes: 

Employee Type Codes† 

FT = full-time MA = management UN = union NX = nonexempt 
PT = part-time NM = nonmgmt NU = nonunion OT = other 

If you offer more than one health plan, please copy this section and attach a 
completed copy for each additional plan you offer. 

Health plan name:
Group number: 

Policy tier

Date began contributing at least 50% (mm/yy)* 
Total premium 

Employer contribution for type code† 

Employer contribution for type code† 

Employer contribution for type code† 

Individual 
$ 
$ 
$ 
$ 

Family 
$ 
$ 
$ 
$
Two-person policies (if offered) 

Couple (two adults) 
$ 
$ 
$ 
$ 
Dual (one adult, one child)
$ 
$ 
$ 
$ 
*If the date you began contributing at least 50% toward health insurance is 
before 1996, an approximate year is sufficient. 

Please indicate below the period during which the rates are effective: 

Start date:
End date: 

Section 3 - Employer Rules and Responsibilities 

By signing below, the employer agrees to do all of the following: 

Treat all employee data received from the Commonwealth confidentially and in 
accordance with the requirements of the Fair Information Practices Act (M.G.L. 
c. 66A), whether or not the person is still an employee or the employer is 
participating in the Insurance Partnership. 

Report any changes to any information requested on this form to its Insurance 
Partnership administrative entity within 10 business days of the change. 

Agree to adjust any qualified employee’s payroll withholdings related to health-
insurance coverage by the amount of premium assistance payments issued by the 
Division, as soon as possible, but no later than 30 days after notification of 
the premium assistance amount. 

Submit monthly health-insurance premiums by the due date of the premium bill. 

Resolve overpayments and underpayments as directed by the Division and/or the 
appropriate Insurance Partnership administrative entity. 

If determined eligible for the Insurance Partnership, 
Business name 

will comply with all rules listed above and with the provisions of the 
Division’s regulations governing participation in the Insurance Partnership, 
found at 130 CMR 650.000. (A copy of the regulations will be provided by the 
Insurance Partnership administrative entity from which you received this 
application.) I understand that my business may be terminated from the Insurance 
Partnership if it fails to follow any of the above rules or the regulations at 
130 CMR 650.000. I further understand that my business’s termination from the 
Insurance Partnership may also result in the termination of premium assistance 
for my employees. 

I certify under penalty of perjury that the information provided on this 
application is correct and complete to the best of my knowledge. 


Employer’s signature
Title
Date 

IP-ER-APP (12/99)