EBSA Form 700

Entity Mandating Form: Department of Labor's Employee Benefits Security Administration (EBSA).

Applicability: The Affordable Care Act (ACA) requires group health plans to cover certain preventive care services, including contraceptives, without cost sharing. An employer with religious or moral objections to covering contraceptives may voluntarily opt out of the requirement. The employer may self-certify to its health insurance issuer (for insured health plans) or a third-party administrator (for self-insured plans) that it qualifies for this optional accommodation. (Alternatively, the employer may notify the Department of Health and Human Services of its objections.)

Obtaining This Form: An employer may download this form directly from the EBSA website.

Additional Resources

Department of Labor

Employee Benefits Security Administration