Health Benefit Exchange

SHOP Eligibility Form

To be eligible to purchase health insurance for employees through the Small Business Health Options Program (SHOP) in Virginia, your small business must attest to meeting all the following criteria:

Have a primary business address in Virginia
Have from 1 – 50 full-time equivalents (FTE employees). Calculate your FTEs.
Offer SHOP coverage to all full-time employees

Note:

Small Businesses in Virginia have the option to provide all plans offered by a SHOP carrier (vertical choice).
Small businesses in Virginia must meet the Minimum Participation Rate (MPR) of 70%.

* Required Fields

Business Name

Business Representative Name and Title

Business Phone Number

Business Email Address

Business Address (Street and/or PO Box)

City

State

Zip code

Qualifications

Response to Qualification Questions

Yes No

If EACH of the Qualification Statements above is correct, select YES; otherwise, select NO.

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