Department of Workforce Service Employer's Health Insurance Information
DWS 116M Form
The purpose of this form is to disclose any health benefits that you received from BYU to the State of Utah's Department of Workforce Service in order to determine the assistance you qualify for.
Please feel free to download the blank form attached below. To ensure that your request will not be delayed, the employed person should fill out their name, date of birth, and eREP Case number. DO NOT INCLUDE YOUR SSN (DWS will be able to locate your file with your case name and number).
We need a Signed Release form in conjunction with your request.
You can submit this completed form and signed release to our office. Once we have completed the form, we can fax it directly to the Department of Workforce Services for you. We will then send a scanned copy of the completed form to your email address.
Employment Verification Hub
2024 WSC
Open: Mon-Fri 8am-5pm
Email us: employment-verification@byu.edu
Or leave a message: 801-422-0818
Fax: 801-422-0640