8963 Report of Health Insurance Provider Information

REG-118315-12 - Health Insurance Providers Fee and Form 8963, Report of Health Insurance Provider Information

Form 8963

Form 8963, Report of Health Insurance Provider Information

OMB: 1545-2249

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Form 8963 (Rev. January 2020)

Department of the Treasury Internal Revenue Service

Report of Health Insurance Provider Information

  • Read the instructions before you complete Form 8963.


OMB No.1545-2249

Publicly Available Information

Check only one box below. See instructions.

Single-person covered entity: Designated entity:

1 Single-person covered entity 2a Agent of an affiliated group

2b Other

Corrected report (see instructions)

Employer identification number (EIN)

Number of controlled group members included in Schedule A (see instructions)

Reporting year


2020

Entity name


Shape2 Shape3 Shape4 Entity name (continued)


Address (number and street). If you have a P.O. box, see instructions.


Address (continued)








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City, town, or post office (For foreign addresses, complete fields below. See instructions.)

State

ZIP code

Foreign country name

Foreign province/state/county

Foreign postal code

PART I



Signature of Official Signing on Behalf of the Single-Person Covered Entity or Designated Entity (Agent of an Affiliated Group or Other Designated Entity) and Consent by the Designated Entity (if applicable)

Under penalties of perjury, I declare that I have examined this report, including accompanying statements, and, to the best of my knowledge and belief, it is true, correct, and complete. I further certify that I am an officer of the single-person covered entity or the designated entity, and that I am duly authorized to sign this report on behalf of that covered entity.


If box 2a or 2b is checked, I also declare that the above named entity is the agent of an affiliated group or other designated entity (as per the instructions). I understand that the designated entity will receive IRS communications relating to the fee imposed by ACA section 9010 and is to pay this fee to the IRS on behalf of the controlled group. Each person that is a controlled group member at the end of the day on December 31, 2019, is jointly and severally liable for this fee. I further declare that each controlled group member identified on this report consents to the choice of the designated entity indicated on this report. Each person who is a controlled group member at the end of the day on December 31, 2019, and who would qualify as a covered entity in 2020 if it were a single-person covered entity, is jointly and severally liable for any applicable penalty under ACA section 9010. (If the designated entity is selected by the IRS, each controlled group member in this report is deemed to consent to the choice of designated entity.)


Sign

Here

Do not sign Form 8963 for electronically filed reports. See instructions.

Signature of official

Date signed

Business phone number

Business fax number

Printed name of signing official

Title of signing official

PART II

Alternate Contact Person Designee (see instructions)

Shape9 Shape10 Do you want to designate an employee to discuss this report with the IRS? . . . . . . . . . . . . . . . . . . . . . . . Yes No


Name of designee

Designee phone number

Title of designee

Designee fax number

Shape11 Shape12 You may be required to file Form 8963 electronically. See the separate instructions for more information about how to file Form 8963.


For Paperwork Reduction Act Notice, see the separate instructions.


Page 1 of 2


Cat. No. 37785K


Form 8963 (Rev. 1-2020)

Publicly Available Information

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Schedule A

Single-Person Covered Entity or Controlled Group Member Information Page 2 of 2

On the first line, list information for the single-person covered entity or designated entity, whichever applies. Next, for a controlled group, separately list information for every person who is a controlled group member at the end of the day on December 31, 2019, and who would qualify as a covered entity in 2020 if it were a single-person covered entity. See instructions.


(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)

(j)




Employer identification number (EIN)



Entity name


Address (number and street, city, state, postal (ZIP) code, and country). If you have a P.O. box or a foreign address, see instructions.



NAIC

code



NAIC

group code



Direct premiums written



MLR rebates



Stand-alone dental or vision direct premiums written

Net premiums written. Subtract column (g) from column (f) and combine the result with column (h).

[(f) - (g) + (h)]


Amount in column (i) attributable to 501(c)(3), 501(c)(4),

501(c)(26), or 501(c)(29) entities. Enter qualifying paragraph and related premiums.

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Form 8963 (Rev. 1-2020)

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorBrinson Martha R
File Modified0000-00-00
File Created2021-01-13

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