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

Enter the covered individual's first (given) name. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's middle initial or middle name; leave blank if none. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's last name or family name (surname). Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's Social Security number or other taxpayer identification number as provided. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's date of birth if the SSN or other TIN is not available. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage for all 12 months of the year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during January. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during February. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during March. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during April. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during May. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during June. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during July. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during August. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during September. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during October. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during November. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during December. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's first (given) name. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's middle initial. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's last name (family name or surname). Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's Social Security number (SSN) or other taxpayer identification number (TIN). Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's date of birth if the SSN or other TIN is not available. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 19 was enrolled in coverage for the entire 12-month period. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 19 was enrolled in coverage for January. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 19 was enrolled in coverage for February. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 19 was enrolled in coverage for March. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 19 was enrolled in coverage for April. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 19 was enrolled in coverage for May. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 19 was enrolled in coverage for June. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 19 was enrolled in coverage for July. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 19 was enrolled in coverage for August. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 19 was enrolled in coverage for September. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 19 was enrolled in coverage for October. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 19 was enrolled in coverage for November. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 19 was enrolled in coverage for December. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's first (given) name as it should appear on the form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's middle initial (single letter) or leave blank if none. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's last name (family or surname). Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's Social Security number or other taxpayer identification number (include digits and any dashes as applicable). Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's date of birth. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in employer-provided self-insured coverage for all 12 months of the calendar year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for January. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for February. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for March. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for April. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for May. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for June. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for July. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for August. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for September. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for October. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for November. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for December. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's first name. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's middle initial. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's last name (family name). Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's Social Security number or other taxpayer identification number. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's date of birth. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual had employer-provided self-insured coverage for all 12 months of the year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for January. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for February. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for March. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for April. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for May. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for June. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for July. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for August. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for September. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for October. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for November. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for December. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's first (given) name. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's middle initial (single letter). Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's last name (family or surname). Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's Social Security number or other taxpayer identification number exactly as issued. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Provide the covered individual's date of birth if their SSN or other TIN is not available. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage for all 12 months of the year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during January. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during February. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during March. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during April. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during May. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during June. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during July. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during August. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during September. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during October. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during November. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the individual was enrolled in coverage during December. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's first (given) name as it should appear on the form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's middle initial, if any; leave blank if none. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's last (family) name or surname. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's Social Security number or other taxpayer identification number, or leave blank if not available. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's date of birth if an SSN or other TIN is not available. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 23 had employer-provided coverage for all 12 months of the tax year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 23 was enrolled in coverage during January of the tax year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 23 was enrolled in coverage during February of the tax year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 23 was enrolled in coverage during March of the tax year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 23 was enrolled in coverage during April of the tax year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 23 was enrolled in coverage during May of the tax year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 23 was enrolled in coverage during June of the tax year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 23 was enrolled in coverage during July of the tax year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 23 was enrolled in coverage during August of the tax year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 23 was enrolled in coverage during September of the tax year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 23 was enrolled in coverage during October of the tax year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 23 was enrolled in coverage during November of the tax year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 23 was enrolled in coverage during December of the tax year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's first name as it should appear on the form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's middle initial (one letter) if they have one; leave blank if none. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's last name (surname) as it should appear on the form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's Social Security number or other taxpayer identification number. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's date of birth if the SSN or other TIN is not available. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual in row 24 was enrolled in employer-provided self-insured coverage for all 12 months of the year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual in row 24 had coverage during January. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual in row 24 had coverage during February. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual in row 24 had coverage during March. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual in row 24 had coverage during April. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual in row 24 had coverage during May. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual in row 24 had coverage during June. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual in row 24 had coverage during July. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual in row 24 had coverage during August. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual in row 24 had coverage during September. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual in row 24 had coverage during October. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual in row 24 had coverage during November. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual in row 24 had coverage during December. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's first (given) name exactly as it should appear on the form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's middle initial; leave blank if none. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's last name (family or surname) exactly as it should appear on the form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's Social Security number or other taxpayer identification number. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's date of birth if their SSN or other TIN is not available. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual on row 25 was enrolled in coverage for all 12 months of the year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual on row 25 was enrolled in coverage in January. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual on row 25 was enrolled in coverage in February. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual on row 25 was enrolled in coverage in March. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual on row 25 was enrolled in coverage in April. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual on row 25 was enrolled in coverage in May. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual on row 25 was enrolled in coverage in June. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual on row 25 was enrolled in coverage in July. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual on row 25 was enrolled in coverage in August. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual on row 25 was enrolled in coverage in September. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual on row 25 was enrolled in coverage in October. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual on row 25 was enrolled in coverage in November. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual on row 25 was enrolled in coverage in December. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's full name (first name, middle initial, last name). Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the individual's Social Security number or other taxpayer identification number exactly as issued (include dashes if you normally use them). Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's date of birth. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter 'Yes' if the individual was covered for all 12 months of the year, otherwise enter 'No'. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

List the months the individual had coverage during the year using month names or standard three-letter abbreviations separated by commas (for example: Jan, Mar–May). Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for all 12 months of the calendar year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage during January. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage during February. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage during March. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage during April. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage during May. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage during June. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage during July. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage during August. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage during September. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage during October. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage during November. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage during December. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's first name as it should appear on the form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's middle initial (single letter), or leave blank if none. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's last name (family name or surname). Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's Social Security Number or other taxpayer identification number (include dashes if you normally use them). Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's date of birth; provide this only if SSN or other TIN is not available. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for all 12 months of the calendar year reported on this form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for January of the calendar year reported on this form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for February of the calendar year reported on this form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for March of the calendar year reported on this form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for April of the calendar year reported on this form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for May of the calendar year reported on this form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for June of the calendar year reported on this form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for July of the calendar year reported on this form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for August of the calendar year reported on this form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for September of the calendar year reported on this form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for October of the calendar year reported on this form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for November of the calendar year reported on this form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for December of the calendar year reported on this form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's first name exactly as it appears on official records. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's middle initial, or leave blank if none. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's last name (surname or family name) exactly as it appears on official records. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's Social Security Number or other taxpayer identification number as used on tax documents. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's date of birth if an SSN or other TIN is not available. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual on row 28 was enrolled in coverage for all 12 months of the year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual on row 28 was enrolled in coverage in January. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual on row 28 was enrolled in coverage in February. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual on row 28 was enrolled in coverage in March. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual on row 28 was enrolled in coverage in April. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual on row 28 was enrolled in coverage in May. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual on row 28 was enrolled in coverage in June. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual on row 28 was enrolled in coverage in July. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual on row 28 was enrolled in coverage in August. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual on row 28 was enrolled in coverage in September. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual on row 28 was enrolled in coverage in October. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual on row 28 was enrolled in coverage in November. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check if the covered individual on row 28 was enrolled in coverage in December. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's first name. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's middle initial (single letter). Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's last name (family name or surname). Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's Social Security number or other taxpayer identification number as shown on records. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's date of birth. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the employee was covered for at least one day in January. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the employee was covered for at least one day in February. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the employee was covered for at least one day in March. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the employee was covered for at least one day in April. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the employee was covered for at least one day in May. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Indicate whether the employee was offered health coverage for January. Check the box if coverage was offered. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Indicate whether the employee was offered health coverage for February. Check the box if coverage was offered. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Indicate whether the employee was offered health coverage for March. Check the box if coverage was offered. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Indicate whether the employee was offered health coverage for April. Check the box if coverage was offered. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Indicate whether the employee was offered health coverage for May. Check the box if coverage was offered. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Indicate whether the employee was offered health coverage for June. Check the box if coverage was offered. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Indicate whether the employee was offered health coverage for July. Check the box if coverage was offered. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Indicate whether the employee was offered health coverage for August. Check the box if coverage was offered. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's first (given) name as it should appear on the form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's middle initial (single letter) or leave blank if none. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's last (family) name or surname as it should appear on the form. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's Social Security number or other taxpayer identification number (include dashes if you normally use them). Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the covered individual's date of birth (provide only if SSN or other TIN is not available). Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in the employer-provided/self-insured coverage for all 12 months of the year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for January of the calendar year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for February of the calendar year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for March of the calendar year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for April of the calendar year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for May of the calendar year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for June of the calendar year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for July of the calendar year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for August of the calendar year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for September of the calendar year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for October of the calendar year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for November of the calendar year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Check this box if the covered individual was enrolled in coverage for December of the calendar year. Fill only if 'Employer provided self‑insured coverage' is 'Yes'.

Enter the employee's first (given) name as it appears on official records.

Enter the employee's middle initial or middle name, if available.

Enter the employee's last name (surname) as it appears on official records.

Enter the employee's nine-digit Social Security number (SSN), including any leading zeros.

Enter the employee's street address, including apartment, suite, or unit number if applicable.

Enter the city or town for the employee's mailing address.

Enter the state or province for the employee's address (use the two-letter U.S. state abbreviation or full province name for non-U.S. addresses).

Enter the employee's country followed by the U.S. ZIP code or the foreign postal code for the address.

Enter the employee required contribution amount that applies to all 12 months for row 15.

Enter the employee required contribution amount for January for row 15. Fill only if 'Contribution - All 12 Months' is not filled.

Enter the employee required contribution amount for February for row 15. Fill only if 'Contribution - All 12 Months' is not filled.

Enter the employee required contribution amount for March for row 15. Fill only if 'Contribution - All 12 Months' is not filled.

Enter the employee required contribution amount for April for row 15. Fill only if 'Contribution - All 12 Months' is not filled.

Enter the employee required contribution amount for May for row 15. Fill only if 'Contribution - All 12 Months' is not filled.

Enter the employee required contribution amount for June for row 15. Fill only if 'Contribution - All 12 Months' is not filled.

Enter the employee required contribution amount for July for row 15. Fill only if 'Contribution - All 12 Months' is not filled.

Enter the employee required contribution amount for August for row 15. Fill only if 'Contribution - All 12 Months' is not filled.

Enter the employee required contribution amount for September for row 15. Fill only if 'Contribution - All 12 Months' is not filled.

Enter the employee required contribution amount for October for row 15. Fill only if 'Contribution - All 12 Months' is not filled.

Enter the employee required contribution amount for November for row 15. Fill only if 'Contribution - All 12 Months' is not filled.

Enter the employee required contribution amount for December for row 15. Fill only if 'Contribution - All 12 Months' is not filled.

Enter the employer's full legal or business name as it should appear on official tax documents.

Enter the employer's Employer Identification Number (EIN) assigned by the IRS.

Enter the employer's street address for mailing, including apartment, suite, room number, or P.O. box if applicable.

Provide the employer's main contact telephone number for this employer, including area code as needed.

Enter the city or town where the employer's mailing address is located.

Enter the state or province for the employer's mailing address.

Enter the country and ZIP code or foreign postal code for the employer's mailing address.

Check this box when the entire form was issued in error and should be voided (the form is not valid and should not be used).

Check this box when the form corrects information that was previously reported on an earlier Form 1095‑C.

Enter the Offer of Coverage code that describes the employee’s coverage status for the entire year (use the numeric code per the Form 1095-C instructions).

Enter the Offer of Coverage code that indicates the type of health coverage offered to the employee for January, using the numeric code from the Form 1095-C instructions. Fill only if 'Offer of Coverage — All 12 Months' is not filled.

Enter the Offer of Coverage code that indicates the type of health coverage offered to the employee for February, using the numeric code from the Form 1095-C instructions. Fill only if 'Offer of Coverage — All 12 Months' is not filled.

Enter the Offer of Coverage code that indicates the type of health coverage offered to the employee for March, using the numeric code from the Form 1095-C instructions. Fill only if 'Offer of Coverage — All 12 Months' is not filled.

Enter the Offer of Coverage code that indicates the type of health coverage offered to the employee for April, using the numeric code from the Form 1095-C instructions. Fill only if 'Offer of Coverage — All 12 Months' is not filled.

Enter the Offer of Coverage code that indicates the type of health coverage offered to the employee for May, using the numeric code from the Form 1095-C instructions. Fill only if 'Offer of Coverage — All 12 Months' is not filled.

Enter the Offer of Coverage code that indicates the type of health coverage offered to the employee for June, using the numeric code from the Form 1095-C instructions. Fill only if 'Offer of Coverage — All 12 Months' is not filled.

Enter the Offer of Coverage code that indicates the type of health coverage offered to the employee for July, using the numeric code from the Form 1095-C instructions. Fill only if 'Offer of Coverage — All 12 Months' is not filled.

Enter the Offer of Coverage code that indicates the type of health coverage offered to the employee for August, using the numeric code from the Form 1095-C instructions. Fill only if 'Offer of Coverage — All 12 Months' is not filled.

Enter the Offer of Coverage code that indicates the type of health coverage offered to the employee for September, using the numeric code from the Form 1095-C instructions. Fill only if 'Offer of Coverage — All 12 Months' is not filled.

Enter the Offer of Coverage code that indicates the type of health coverage offered to the employee for October, using the numeric code from the Form 1095-C instructions. Fill only if 'Offer of Coverage — All 12 Months' is not filled.

Enter the Offer of Coverage code that indicates the type of health coverage offered to the employee for November, using the numeric code from the Form 1095-C instructions. Fill only if 'Offer of Coverage — All 12 Months' is not filled.

Enter the Offer of Coverage code that indicates the type of health coverage offered to the employee for December, using the numeric code from the Form 1095-C instructions. Fill only if 'Offer of Coverage — All 12 Months' is not filled.

Check this box if the employer provided self‑insured health coverage (then complete Part III by entering information for each individual enrolled, including the employee).

Enter the employee's age in years as of January 1 of the tax year.

Enter the two‑digit month when the employer's health plan started for the year (for example, 01 for January, 12 for December).

Enter the Section 4980H safe harbor or other relief code from the Form 1095-C instructions that applies to the employee for the entire year (all 12 months).

Enter the Section 4980H safe harbor or other relief code from the Form 1095-C instructions that applies to the employee for January. Fill only if 'Section 4980H Safe Harbor Code (All 12 Months)' is not filled.

Enter the Section 4980H safe harbor or other relief code from the Form 1095-C instructions that applies to the employee for February. Fill only if 'Section 4980H Safe Harbor Code (All 12 Months)' is not filled.

Enter the Section 4980H safe harbor or other relief code from the Form 1095-C instructions that applies to the employee for March. Fill only if 'Section 4980H Safe Harbor Code (All 12 Months)' is not filled.

Enter the Section 4980H safe harbor or other relief code from the Form 1095-C instructions that applies to the employee for April. Fill only if 'Section 4980H Safe Harbor Code (All 12 Months)' is not filled.

Enter the Section 4980H safe harbor or other relief code from the Form 1095-C instructions that applies to the employee for May. Fill only if 'Section 4980H Safe Harbor Code (All 12 Months)' is not filled.

Enter the Section 4980H safe harbor or other relief code from the Form 1095-C instructions that applies to the employee for June. Fill only if 'Section 4980H Safe Harbor Code (All 12 Months)' is not filled.

Enter the Section 4980H safe harbor or other relief code from the Form 1095-C instructions that applies to the employee for July. Fill only if 'Section 4980H Safe Harbor Code (All 12 Months)' is not filled.

Enter the Section 4980H safe harbor or other relief code from the Form 1095-C instructions that applies to the employee for August. Fill only if 'Section 4980H Safe Harbor Code (All 12 Months)' is not filled.

Enter the Section 4980H safe harbor or other relief code from the Form 1095-C instructions that applies to the employee for September. Fill only if 'Section 4980H Safe Harbor Code (All 12 Months)' is not filled.

Enter the Section 4980H safe harbor or other relief code from the Form 1095-C instructions that applies to the employee for October. Fill only if 'Section 4980H Safe Harbor Code (All 12 Months)' is not filled.

Enter the Section 4980H safe harbor or other relief code from the Form 1095-C instructions that applies to the employee for November. Fill only if 'Section 4980H Safe Harbor Code (All 12 Months)' is not filled.

Enter the Section 4980H safe harbor or other relief code from the Form 1095-C instructions that applies to the employee for December. Fill only if 'Section 4980H Safe Harbor Code (All 12 Months)' is not filled.

Enter the employee's ZIP code that applies to all 12 months if it did not change; include the 5‑digit ZIP or ZIP+4 if available.

Enter the employee's ZIP code for January; include the 5‑digit ZIP or ZIP+4 if available. Fill only if 'ZIP Code (All 12 Months)' is not filled.

Enter the employee's ZIP code for February; include the 5‑digit ZIP or ZIP+4 if available. Fill only if 'ZIP Code (All 12 Months)' is not filled.

Enter the employee's ZIP code for March; include the 5‑digit ZIP or ZIP+4 if available. Fill only if 'ZIP Code (All 12 Months)' is not filled.

Enter the employee's ZIP code for April; include the 5‑digit ZIP or ZIP+4 if available. Fill only if 'ZIP Code (All 12 Months)' is not filled.

Enter the employee's ZIP code for May; include the 5‑digit ZIP or ZIP+4 if available. Fill only if 'ZIP Code (All 12 Months)' is not filled.

Enter the employee's ZIP code for June; include the 5‑digit ZIP or ZIP+4 if available. Fill only if 'ZIP Code (All 12 Months)' is not filled.

Enter the employee's ZIP code for July; include the 5‑digit ZIP or ZIP+4 if available. Fill only if 'ZIP Code (All 12 Months)' is not filled.

Enter the employee's ZIP code for August; include the 5‑digit ZIP or ZIP+4 if available. Fill only if 'ZIP Code (All 12 Months)' is not filled.

Enter the employee's ZIP code for September; include the 5‑digit ZIP or ZIP+4 if available. Fill only if 'ZIP Code (All 12 Months)' is not filled.

Enter the employee's ZIP code for October; include the 5‑digit ZIP or ZIP+4 if available. Fill only if 'ZIP Code (All 12 Months)' is not filled.

Enter the employee's ZIP code for November; include the 5‑digit ZIP or ZIP+4 if available. Fill only if 'ZIP Code (All 12 Months)' is not filled.

Enter the employee's ZIP code for December; include the 5‑digit ZIP or ZIP+4 if available. Fill only if 'ZIP Code (All 12 Months)' is not filled.