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Filling out the Employer Appeal Request Form electronically

To fill out an Employer Appeal Request Form (PDF), youโ€™ll need to download it onto your computer first.

Step 1: Download the Employer Appeal Request Form

Right click on this Employer Appeal Request Form (PDF).

Step 2: Save the form on your computer

  • Download the form on your computer
    • Chrome and Firefox users: Choose "Save Link Asโ€ฆ"
    • Microsoft Edge users: Choose "Save Target Asโ€ฆ"
    • Safari users: Choose "Download Linked File asโ€ฆ"
  • Select a location on your computer to save this application โ€“ on the desktop, in your documents folder, or somewhere else it will be easy to find.
  • Click Save.

Step 3: Open the form and fill it out

When youโ€™re ready to fill out the Employer Appeal Request Form (PDF):
  • Minimize this web browser window
  • Locate the Employer Appeal Request Form (PDF) you downloaded to your computer in Step 2.
  • Click on the document to open it. Youโ€™re ready to start filling it out.
  • When youโ€™ve finished filling out the form, save it, print it, and mail it, or fax it to the Health Insurance Marketplaceยฎ at the location shown on the form.