Filling out the Employer Appeal Request Form electronically
To fill out an Employer Appeal Request Form (PDF), you’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 As…"
- Internet Explorer users: Choose "Save Target As…"
- Safari users: Choose "Download Linked File as…"
- Select a location on your computer to save this application – 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 you’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. You’re ready to start filling it out.
- When you’ve finished filling out the form, save it, print it, and mail it, or fax it to the Health Insurance Marketplace® at the location shown on the form.