IRS FORM 1095-C

Version 1.2 by steveny on 2023/05/04 15:16

FORM 1095-C

Click on the individual boxes below for specific IRS Instructions

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Part I: Employee Applicable Large Employer Member (ALE Member/Employer)

Employee

Line 1, Employee's Name

Line 2, Employee's Social Security Number (including dashes)

Lines 3-6, Employee's Complete Address

Employer (Should match information on 1094-C)

Line 7, Employer's Name

Line 8, Employer's EIN

Lines 9 and 11-13, Employer's Complete Address

Line 10, Contact Person's Telephone Number

Part II: Employee Offer and Coverage

Employee Offer and Coverage - Plan Start Month

Line 14, Offer of Coverage (Code)

Line 15, Employee Share of Lowest Cost Monthly Premium, for Self-Only Minimum Value Coverage

Line 16, Applicable Section 4980H safe Harbor (Code, if applicable)

Part III: Covered Individuals

Part III Lines 17-22, Covered Individuals

Part III: Covered Individuals

Column (a), Covered Individual's Name

Column (b), Covered Individual's Social Security Number (SSN)

Column (c), Covered Individual's Birthdate (MM/DD/YYY) if Social Security Number (SSN) is not available

Column (d), Covered all 12 months

Column (e), Months of Coverage