8963 Report of Health Insurance Provider Information

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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. Go to www.irs.gov/Form8963 for instructions and the latest information.				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

Entity name (continued)

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

Address (continued)

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)

^{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

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.

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Cat. No. 37785K

Form 8963 (Rev. 1-2020)

Publicly Available Information

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)