Form 1095-C Form 1095-C Employer-Provided Health Insurance Offer and Coverage

Version C, Cycle 19
Fillable Fields: 10pt Helvetica LT, Black Checkbox Size: 12.5 Checkmark: Default

1095-C

Form
Department of the Treasury
Internal Revenue Service

Part I

▶ Information

Applicable Large Employer Member (Employer)

1 Name of employee

2 Social security number (SSN)

3 Street address (including apartment no.)
5 State or province

4 City or town

Part II

2014

7 Name of employer

8 Employer identification number (EIN)

9 Street address (including room or suite no.)

10 Contact telephone number

6 Country and ZIP or foreign postal code 11 City or town

12 State or province

13 Country and ZIP or foreign postal code

INTERNAL USE ONLY
Draft As Of
February 4, 2014

Employee Offer and Coverage
All 12 Months

14 Offer of
Coverage (enter
required code)
15 Employee Share
of Lowest Cost
Monthly Premium,
for Self-Only
Minimum Value
Coverage
16 Applicable
Section 4980H Safe
Harbor (enter code,
if applicable)

Part III

OMB No. 1545-2251

CORRECTED

about Form 1095-C and its separate instructions is at www.irs.gov/f1095c.

Employee

600115

VOID

Employer-Provided Health Insurance Offer and Coverage

$

Jan

$

Feb

$

Mar

$

Apr

$

May

$

June

$

July

$

Aug

Sept

$

Oct

$

$

Nov

$

Dec

$

Covered Individuals

If Employer provided self-insured coverage, check the box and enter the information for each covered individual.
(a) Name of covered individual(s)

(b) SSN

(c) DOB (If SSN is
not available)

(d) Covered
all 12 months

(e) Months of Coverage

Jan

Feb

Mar

Apr

May

June

July

Aug

Sept

Oct

Nov

Dec

17

18

19

20

21

22
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 60705M

Form 1095-C (2014)

Version C, Cycle 19
Fillable Fields: 10pt Helvetica LT, Black Checkbox Size: 12.5 Checkmark: Default

600215
Page 2

Form 1095-C (2014)

Instructions for Recipient
You are receiving this Form 1095-C because your employer is an Applicable Large Employer
subject to the employer shared responsibility provision in the Affordable Care Act. This Form
1095-C includes information about the health insurance coverage offered to you by your
employer. Form 1095-C, Part II, includes information about the coverage, if any, your employer
offered to you and your spouse and dependent(s). If you purchased health insurance coverage
through the Health Insurance Marketplace and wish to claim the premium tax credit, this
information will assist you in determining whether you are eligible. For more information about
the premium tax credit, see Pub. 974, Premium Tax Credit (PTC). You may receive multiple
Forms 1095-C if you had multiple employers during the year that were Applicable Large
Employers (for example, you left employment with one Applicable Large Employer and began a
new position of employment with another Applicable Large Employer). In that situation, each
Form 1095-C would have information only about the health insurance coverage offered to you
by the employer identified on the form. If your employer is not an Applicable Large Employer it is
not required to furnish you a Form 1095-C providing information about the health coverage it
offered.
In addition, if you, or any other individual who is offered health coverage because of their
relationship to you (referred to here as family members), enrolled in your employer's health plan
and that plan is a type of plan referred to as a "self-insured" plan, Form 1095-C, Part III provides
information to assist you in completing your income tax return by showing you or those family
members had qualifying health coverage (referred to as "minimum essential coverage") for some
or all months during the year.
If your employer provided you or a family member health coverage through an insured health
plan or in another manner, the issuer of the insurance or the sponsor of the plan providing the
coverage will furnish you information about the coverage separately on Form 1095-B, Health
Coverage. Similarly, if you or a family member obtained minimum essential coverage from
another source, such as a government-sponsored program, an individual market plan, or
miscellaneous coverage designated by the Department of Health and Human Services, the
provider of that coverage will furnish you information about that coverage on Form 1095-B. If
you or a family member enrolled in a qualified health plan through a Health Insurance
Marketplace, the Health Insurance Marketplace will report information about that coverage on
Form 1095-A, Health Insurance Marketplace Statement.

Part II. Employer Offer and Coverage, Lines 14–16
Line 14. The codes listed below for line 14 describe the coverage that your employer offered to
you and your spouse and dependent(s), if any. This information relates to eligibility for coverage
subsidized by the premium tax credit for you, your spouse, and dependent(s). For more
information about the premium tax credit, see Pub. 974.
1A. Minimum essential coverage providing minimum value offered to you with an employee
contribution for self-only coverage equal to or less than $1,108.65 (9.5% of the 48 contiguous
states single federal poverty line) and minimum essential coverage offered to your spouse and
dependent(s) (referred to here as a Qualifying Offer). This code may be used to report for specific
months for which a Qualifying Offer was made, even if you did not receive a Qualifying Offer for
all 12 months of the calendar year.
1B. Minimum essential coverage providing minimum value offered to you and minimum essential
coverage NOT offered to your spouse or dependent(s).
1C. Minimum essential coverage providing minimum value offered to you and minimum essential
coverage offered to your dependent(s) but NOT your spouse.
1D. Minimum essential coverage providing minimum value offered to you and minimum essential
coverage offered to your spouse but NOT your dependent(s).
1E. Minimum essential coverage providing minimum value offered to you and minimum essential
coverage offered to your dependent(s) and spouse.
1F. Minimum essential coverage NOT providing minimum value offered to you, or you and your
spouse or dependent(s), or you, your spouse, and dependent(s).
1G. You were NOT a full-time employee for any month of the calendar year but were enrolled in
self-insured employer-sponsored coverage for one or more months of the calendar year. This
code will be entered in the All 12 Months box on line 14.
1H. No offer of coverage (you were NOT offered any health coverage or you were offered
coverage that is NOT minimum essential coverage).
1I. Your employer claimed "Qualifying Offer Transition Relief" for 2015 and for at least one
month of the year you (and your spouse or dependent(s)) did not receive a Qualifying Offer. Note
that your employer has also provided a contact number at which you may request further
information about the health coverage, if any, you were offered (see line 10).
Line 15. This line reports the employee share of the lowest-cost monthly premium for self-only
minimum essential coverage providing minimum value that your employer offered you. The
amount reported on line 15 may not be the amount you paid for coverage if, for example, you
chose to enroll in more expensive coverage such as family coverage. Line 15 will show an
amount only if code 1B, 1C, 1D, or 1E is entered on line 14. If you were offered coverage but not
required to contribute any amount towards the premium, this line will report a “0.00” for the
amount.
Line 16. This line provides the IRS information to administer the employer shared responsibility
provisions. None of this information affects your eligibility for the premium tax credit. For more
information about the employer shared responsibility provisions, see IRS.gov.

INTERNAL USE ONLY
Draft As Of
February 4, 2014

TIP

Employers are required to furnish Form 1095-C only to the employee. As the
recipient of this Form 1095-C, you should provide a copy to any family members
covered under a self-insured employer-sponsored plan listed in Part III if they
request it for their records.

Part I. Employee
Lines 1–6. Part I, lines 1–6, reports information about you, the employee.
Line 2. This is your social security number (SSN). For your protection, this form may show only
the last four digits of your SSN. However, the issuer is required to report your complete SSN to
the IRS.
If you do not provide your SSN and the SSNs of all covered individuals to the plan
administrator, the IRS may not be able to match the Form 1095-C to determine that
you and the other covered individuals have complied with the individual shared
CAUTION
responsibility provision. For covered individuals other than the employee listed in
Part I, a Taxpayer Identification Number (TIN) may be provided instead of an SSN.

!
▲

Part I. Applicable Large Employer Member (Employer)
Lines 7–13. Part I, lines 7–13, reports information about your employer.
Line 10. This line includes a telephone number for the person whom you may call if you have
questions about the information reported on the form.

Part III. Covered Individuals, Lines 17–22
Part III reports the name, SSN (or TIN for covered individuals other than the employee listed in
Part I), and coverage information about each individual (including any full-time employee and
non-full-time employee, and any employee's family members) covered under the employer's
health plan, if the plan is "self-insured." A date of birth will be entered in column (c) only if an
SSN (or TIN for covered individuals other than the employee listed in Part I) is not entered in column
(b). Column (d) will be checked if the individual was covered for at least one day in every month
of the year. For individuals who were covered for some but not all months, information will be
entered in column (e) indicating the months for which these individuals were covered. If there are
more than 6 covered individuals, you will receive one or more additional Forms 1095-C that
continue Part III.