HBE 15-007 (03/08/2017)
EMPLOYER REQUEST FOR HEARING
Print additional forms to request hearings for multiple employees.
IMPORTANT: While it may be helpful to get ahead of the issue by appealing the initial employer notification, any penalties
for failure to comply with the section 4980H of the tax code (employer coverage mandate) will ultimately be determined by
the IRS based on tax filings submitted after the end of the tax year.
An appeal is NOT a requirement. You can ask us to help you resolve this issue by calling the Appeals Program at 1-855-
859-2512 for more information.
*required fields
Today’s date
Application ID # on notification*
Date on notification*
COMPANY/EMPLOYER INFORMATION
Name of Business/Employer*
Employer Representative Name Title
Business Mailing Address
City, State
Zip
Employer Representative Telephone #*
Employer Rep Email Address*
Did you offer the employee named below
health insurance that meets the
requirements of the Affordable Care Act?
☐ Yes ☐ No ☐ Not yet
How much do you charge an employee
for your lowest cost plan that meets
ACA requirements?
$___________________/month
EMPLOYEE INFORMATION
Employee First Name*
Employee Last Name*
Employee’s Work Phone #*
Do NOT send any other documents or evidence with this form.
EMAIL to: appeals@wahbexchange.org FAX to: 360-841-7653
MAIL to: WAHBE Employer Appeal
PO Box 1757 Questions? 1-855-859-2512
Olympia, WA 98507-1757
EMPLOYER REPRESENTATIVE SIGNATURE (REQUIRED)
I am authorized to represent the above-named business. On behalf of the business, I request WAHBE adjudicate a dispute
between this employer and the employee. This employer disputes the employee’s eligibility for Advanced Premium Tax
Credits. The information provided in this form is true and correct, to the best of my knowledge.
Employer Representative signature* Date
X
