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…"
  • Microsoft Edge 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.