Form - Those With Health Plans

All information entered here will be printed on both the English and Spanish version of the Department of Labor's form in the language used when entered in the fields below. When you upload your employee database to us you will be asked to indicate either "E" for English or "S" for Spanish on each record. The "E" or "S" will dictate what form (i.e. English or Spanish) will be printed and mailed to that specific employee. Regardless of the form they receive, the data will appear in the language you enter below and will NOT be translated.

For sections that require textual answers you can do one of the following:

1. Provide your information in BOTH English and Spanish in the space provided.

OR

2. Create two separate jobs. Provide your information below in English ONLY and then upload your employee database for all recipients who should receive an English version. Complete your purchase. Then return to the ACANotice.com web site, begin the process again and provide your information in Spanish ONLY and then upload your employee database for all recipients who should receive a Spanish version.

If you have questions, please contact our office before proceeding. Please click on our contact us link at the top of this page.


Here is some basic information about health coverage offered by this employer:

The following box is provided to explain to the employee the purpose of this form. You may elect to retain the default text, insert your own text, or delete entirely. This will appear on the form to the right of the address area and will not show through the envelope window. All text will be printed on both the English and Spanish version of the Department of Labor's form in the language used when entered in the box below. (Limit is 255 characters.)

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