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

Check this box if the employer met the affordability safe harbor for the month.

Enter the code that corresponds to the type of coverage offered to the employee for the month of February. This is a single character code.

Enter the code that indicates the type of coverage offered to the employee for the month of January. This is a single character code.

Indicate the code that corresponds to the type of coverage offered by the employer for this month. This is a single character field.

Check this box if the employee was covered for at least one day in this month under the employer's health insurance plan.

Check this box if the employee was not offered health insurance coverage for this month.

Check this box if the employee was offered health insurance coverage but did not accept it for this month.

Check this box if the employee was offered health insurance coverage and accepted it for this month.

Check this box if the employee was offered health insurance coverage and accepted it, but the coverage was not effective for this month.

Enter the specific information related to the health insurance coverage offered by the employer for this particular month.

Provide additional details or notes regarding the health insurance coverage for this month, if applicable.

Enter any other relevant information or notes regarding the health insurance coverage for this month.

Enter the code for the type of coverage offered to the employee. This is a 3-character code.

Enter the code for the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage. This is a 2-character code.

Enter the code indicating the type of health coverage offered to the employee.

Enter the amount the employee would pay for the lowest-cost monthly premium for self-only minimum essential coverage.

Enter the code indicating whether the employee was covered by the employer's health plan for each month.

Enter the month and year when the health coverage was offered to the employee.

Enter the code that indicates the type of coverage offered to the employee.

Enter the month and year when the health coverage was offered to the employee.

Enter the type of health coverage offered to the employee (e.g., self-only, family).

Enter the lowest cost monthly premium for self-only minimum essential coverage.

Enter the code indicating the type of coverage offered to the employee.

Enter the number of months the employee was covered by the employer's health plan. Maximum length is 5 characters.

Check this box if the employee was covered for at least one day in January.

Check this box if the employee was covered for at least one day in February.

Check this box if the employee was covered for at least one day in March.

Check this box if the employee was covered for at least one day in April.

Check this box if the employee was covered for at least one day in May.

Indicate whether the employee was offered health coverage for the month of January.

Indicate whether the employee was offered health coverage for the month of February.

Indicate whether the employee was offered health coverage for the month of March.

Indicate whether the employee was offered health coverage for the month of April.

Indicate whether the employee was offered health coverage for the month of May.

Indicate whether the employee was offered health coverage for January.

Indicate whether the employee was offered health coverage for February.

Indicate whether the employee was offered health coverage for March.

Indicate whether the employee was offered health coverage for April.

Indicate whether the employee was offered health coverage for May.

Indicate whether the employee was offered health coverage for June.

Indicate whether the employee was offered health coverage for July.

Indicate whether the employee was offered health coverage for August.

Indicate whether the employee was offered health coverage for September.

Indicate whether the employee was offered health coverage for the month of January.

Indicate whether the employee was offered health coverage for the month of May.

Indicate whether the employee was offered health coverage for the month of June.

Indicate whether the employee was offered health coverage for the month of July.

Indicate whether the employee was offered health coverage for the month of January.

Indicate whether the employee was offered health coverage for the month of February.

Indicate whether the employee was offered health coverage for the month of March.

Indicate whether the employee was offered health coverage for the month of April.

Indicate whether the employee was offered health coverage for the month of May.

Indicate whether the employee was offered health coverage for January. Check the box if coverage was offered.

Indicate whether the employee was offered health coverage for February. Check the box if coverage was offered.

Indicate whether the employee was offered health coverage for March. Check the box if coverage was offered.

Indicate whether the employee was offered health coverage for April. Check the box if coverage was offered.

Indicate whether the employee was offered health coverage for May. Check the box if coverage was offered.

Indicate whether the employee was offered health coverage for June. Check the box if coverage was offered.

Indicate whether the employee was offered health coverage for July. Check the box if coverage was offered.

Indicate whether the employee was offered health coverage for August. Check the box if coverage was offered.

Indicate whether the employee was offered health coverage for January.

Indicate whether the employee was offered health coverage for February.

Indicate whether the employee was offered health coverage for March.

Indicate whether the employee was offered health coverage for April.

Indicate whether the employee was offered health coverage for May.

Indicate whether the employee was offered health coverage for June.

Indicate whether the employee was offered health coverage for July.

Indicate whether the employee was offered health coverage for August.

Indicate whether the employee was offered health coverage for April. Check the box if coverage was offered.

Indicate whether the employee was offered health coverage for the month of April.

Indicate whether health insurance coverage was offered to the employee for the month of April.

Indicate whether the employee was offered health coverage for the month of April. Check the box if coverage was offered.

Check this box if the employee was offered health insurance coverage for the month of April.

Indicate whether the employee was offered health coverage for April. Check the box if coverage was offered.

Check this box if the employee was offered health insurance coverage for April.

Indicate whether the employee was offered health coverage for April. Check the box if coverage was offered.

Indicate whether the employee was offered health insurance coverage for April.

Indicate whether the employee was offered health coverage for August. Check the box if coverage was offered.

Indicate whether the employee was offered health coverage for the month of August.

Indicate whether health insurance coverage was offered to the employee for the month of August.

Indicate whether the employee was offered health coverage for the month of August. Check the box if coverage was offered.

Check this box if the employee was offered health insurance coverage for the month of August.

Indicate whether the employee was offered health coverage for August. Check the box if coverage was offered.

Check this box if the employee was offered health insurance coverage for August.

Indicate whether the employee was offered health coverage for August. Check the box if coverage was offered.

Indicate whether the employee was offered health insurance coverage for August.

Indicate whether the employee was offered health coverage for February. Check the box if coverage was offered.

Indicate whether the employee was offered health coverage for the month of February.

Indicate whether health insurance coverage was offered to the employee for the month of February.

Indicate whether the employee was offered health coverage for the month of February. Check the box if coverage was offered.

Check this box if the employee was offered health insurance coverage for the month of February.

Indicate whether the employee was offered health coverage for February. Check the box if coverage was offered.

Check this box if the employee was offered health insurance coverage for February.

Indicate whether the employee was offered health coverage for February. Check the box if coverage was offered.

Indicate whether the employee was offered health insurance coverage for February.

Indicate whether the employee was offered health coverage for January. Check the box if coverage was offered.

Indicate whether the employee was offered health coverage for the month of January.

Indicate whether health insurance coverage was offered to the employee for the month of January.

Indicate whether the employee was offered health coverage for the month of January. Check the box if coverage was offered.

Check this box if the employee was offered health insurance coverage for the month of January.

Indicate whether the employee was offered health coverage for January. Check the box if coverage was offered.

Check this box if the employee was offered health insurance coverage for January.

Indicate whether the employee was offered health coverage for January. Check the box if coverage was offered.

Indicate whether the employee was offered health insurance coverage for January.

Indicate whether the employee was offered health coverage for July. Check the box if coverage was offered.

Indicate whether the employee was offered health coverage for the month of July.

Indicate whether health insurance coverage was offered to the employee for the month of July.

Indicate whether the employee was offered health coverage for the month of July. Check the box if coverage was offered.

Check this box if the employee was offered health insurance coverage for the month of July.

Indicate whether the employee was offered health coverage for July. Check the box if coverage was offered.

Check this box if the employee was offered health insurance coverage for July.

Indicate whether the employee was offered health coverage for July. Check the box if coverage was offered.

Indicate whether the employee was offered health insurance coverage for July.

Indicate whether the employee was offered health coverage for June. Check the box if coverage was offered.

Indicate whether the employee was offered health coverage for the month of June.

Indicate whether health insurance coverage was offered to the employee for the month of June.

Indicate whether the employee was offered health coverage for the month of June. Check the box if coverage was offered.

Check this box if the employee was offered health insurance coverage for the month of June.

Indicate whether the employee was offered health coverage for June. Check the box if coverage was offered.

Check this box if the employee was offered health insurance coverage for June.

Indicate whether the employee was offered health coverage for June. Check the box if coverage was offered.

Indicate whether the employee was offered health insurance coverage for June.

Indicate whether the employee was offered health coverage for March. Check the box if coverage was offered.

Indicate whether the employee was offered health coverage for the month of March.

Indicate whether health insurance coverage was offered to the employee for the month of March.

Indicate whether the employee was offered health coverage for the month of March. Check the box if coverage was offered.

Check this box if the employee was offered health insurance coverage for the month of March.

Indicate whether the employee was offered health coverage for March. Check the box if coverage was offered.

Check this box if the employee was offered health insurance coverage for March.

Indicate whether the employee was offered health coverage for March. Check the box if coverage was offered.

Indicate whether the employee was offered health insurance coverage for March.

Indicate whether the employee was offered health coverage for May. Check the box if coverage was offered.

Indicate whether the employee was offered health coverage for the month of May.

Indicate whether health insurance coverage was offered to the employee for the month of May.

Indicate whether the employee was offered health coverage for the month of May. Check the box if coverage was offered.

Check this box if the employee was offered health insurance coverage for the month of May.

Indicate whether the employee was offered health coverage for May. Check the box if coverage was offered.

Check this box if the employee was offered health insurance coverage for May.

Indicate whether the employee was offered health coverage for May. Check the box if coverage was offered.

Indicate whether the employee was offered health coverage for September. Check the box if coverage was offered.

Indicate whether the employee was offered health coverage for the month of September.

Indicate whether health insurance coverage was offered to the employee for the month of September.

Indicate whether the employee was offered health insurance coverage for September.

Enter the code for the type of coverage offered to the employee for the month of January. This is a 5-character code.

Enter the code for the type of coverage offered to the employee for the month of February. This is a 5-character code.

Enter the code indicating the type of coverage offered for the month. This is a single character field.

Enter the amount of the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage providing minimum value that is offered to the employee.

Enter the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage providing minimum value that is offered to the employee. This field can contain up to 11 characters.

Enter the code indicating the type of coverage offered for the month.

Check this box if the employee was offered coverage for the month.

Check this box if the employee was not offered coverage for the month.

Check this box if the employee was offered coverage but it did not meet the minimum value standard.

Check this box if the employee was offered coverage that met the minimum value standard.

Check this box if the employee was offered coverage that was affordable based on the federal poverty line safe harbor.

Enter the code indicating the type of coverage offered for the month. This is a single character field.

Enter the amount of the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage.

Check this box if the employee was offered coverage for the month.

Check this box if the employee was not offered coverage for the month.

Check this box if the employee was offered coverage but it did not meet the minimum essential coverage requirements.

Check this box if the employee was offered coverage that met the minimum essential coverage requirements.

Check this box if the employee was offered coverage that met the minimum value standard.

Enter the code indicating the type of coverage offered for the month. This is a single character code.

Enter the amount of the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage providing minimum value that is offered to the employee.

Enter the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage providing minimum value that is offered to the employee. This should be a numeric value up to 11 characters.

Enter any additional information related to the coverage offer for the month.

Check this box if the employee was not offered coverage for the month.

Check this box if the employee was offered coverage but it did not provide minimum value.

Check this box if the employee was offered coverage that was affordable based on the federal poverty line safe harbor.

Check this box if the employee was offered coverage that was affordable based on the rate of pay safe harbor.

Check this box if the employee was offered coverage that was affordable based on the W-2 wages safe harbor.

Enter the code indicating the type of coverage offered for the month. This is a single character code.

Enter the amount of the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage.

Enter the employee's required contribution for the lowest-cost monthly premium for self-only minimum essential coverage. This should be a numeric value up to 11 characters.

Enter the code indicating the safe harbor or other relief for the month, if applicable.

Enter the code indicating the type of coverage offered for the month. This is a single character field.

Enter the code indicating the type of coverage offered for the month. This field may require a specific code based on IRS guidelines.

Enter the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage providing minimum value that is offered to the employee. This should be a numeric value up to 11 characters.

Enter the code indicating the type of coverage offered for the month. This field may require a specific code based on IRS guidelines.

Check this box if the employee was offered health coverage for January.

Check this box if the employee was offered health coverage for February.

Check this box if the employee was offered health coverage for March.

Check this box if the employee was offered health coverage for April.

Check this box if the employee was offered health coverage for May.

Check this box if the employee was offered health coverage for June.

Check this box if the employee was offered health coverage for July.

Check this box if the employee was offered health coverage for August.

Enter the code that indicates the type of coverage offered to the employee for the month. This is a single character field.

Provide additional information or a code related to the coverage offer for the employee for the month.

Enter the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage that provides minimum value. This should be a numeric value up to 11 characters.

Provide any additional details or codes related to the coverage offer for the employee for the month.

Check this box if the employee was not offered coverage for the month.

Check this box if the employee was offered coverage but it did not meet the minimum essential coverage requirements.

Check this box if the employee was offered coverage that met the minimum essential coverage requirements.

Check this box if the employee was offered coverage that met the minimum value standard.

Check this box if the employee was offered coverage that was affordable based on the federal poverty line safe harbor.

Enter the code for the type of coverage offered to the employee for the month. This is a single character code.

Enter the amount of the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage providing minimum value that is offered to the employee.

Enter the code indicating the type of coverage offered for the month. This is a single character code.

Enter the amount of the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage providing minimum value that is offered to the employee.

Enter the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage providing minimum value that is offered to the employee. This should be a numeric value up to 11 characters.

Enter any additional information related to the coverage offer for the month.

Check this box if the employee was not offered coverage for the month.

Check this box if the employee was offered coverage but it did not provide minimum value.

Check this box if the employee was offered coverage that was affordable based on the federal poverty line safe harbor.

Check this box if the employee was offered coverage that was affordable based on the rate of pay safe harbor.

Check this box if the employee was offered coverage that was affordable based on the W-2 wages safe harbor.

Enter the name of the covered individual. This is typically the employee or a dependent who is covered under the employer's health plan.

Enter the name of the covered individual if the employer provides self-insured coverage.

Enter the name of the covered individual if the employer provides self-insured coverage.

Enter the name of the covered individual associated with the employee's health coverage.

Enter the information related to the first covered individual, such as name or identifier.

Enter additional information related to the first covered individual, such as date of birth or other identifier.

Enter further details related to the first covered individual, such as coverage start date.

Enter more information related to the first covered individual, such as coverage end date.

Enter any other relevant information related to the first covered individual.

Enter additional details related to the first covered individual, if applicable.

Enter any final information related to the first covered individual, if necessary.

Enter the name of any individual covered under the employer's self-insured health plan.

Enter the Social Security Number (SSN) or Taxpayer Identification Number (TIN) of any individual covered under the employer's self-insured health plan.

Enter the name of the individual covered under the employer's self-insured health plan.

Enter the Social Security Number (SSN) or Taxpayer Identification Number (TIN) of the covered individual.

Enter the date of birth of the covered individual if SSN or TIN is not available.

Check this box if the employee was covered for at least one day in January under the employer's self-insured health plan.

Enter the name of the covered individual associated with the employee's health plan.

Enter the relationship code of the covered individual to the employee. This is a single character code.

Enter the Social Security Number (SSN) of the covered individual associated with the employee's health plan.

Enter the date of birth of the covered individual if the SSN is not available. Format should be MM/DD/YYYY.

Enter the start date of coverage for the covered individual under the employer's health plan. Format should be MM/DD/YYYY.

Check this box if the covered individual was covered for at least one day in February under the employer's self-insured health plan.

Check this box if the covered individual was covered for at least one day in March under the employer's self-insured health plan.

Enter the name of the covered individual.

Enter the relationship code of the covered individual to the employee. This is a single character code.

Enter the Social Security Number (SSN) of the covered individual.

Enter the Taxpayer Identification Number (TIN) of the covered individual, if applicable. This field has a maximum length of 11 characters.

Enter the date of birth of the covered individual, if the SSN is not available.

Enter the name of the covered individual if the employer provides self-insured coverage.

Enter the name of the covered individual associated with the employee's health coverage.

Enter the name of the covered individual. This field is for listing individuals covered under the employer's health plan.

Check this box if the employee was covered for at least one day in January.

Check this box if the employee was covered for at least one day in February.

Check this box if the employee was covered for at least one day in March.

Check this box if the employee was covered for at least one day in April.

Check this box if the employee was covered for at least one day in May.

Enter the name of the covered individual associated with the employee's health coverage.

Enter the street address of the employee, including apartment number if applicable.

Enter the city or town of the employee's address.

Enter the state or province of the employee's address.

Enter the country and ZIP or foreign postal code of the employee's address.

Check this box if the employee was enrolled in coverage for the month.

Enter the full name of the employee receiving the health insurance coverage.

Enter the middle initial of the employee, if applicable.

Enter the last name of the employee receiving the health insurance coverage.

Enter the Social Security Number (SSN) of the employee. Maximum length is 11 characters.

Enter the employee's name as it appears on their official documents.

Enter the employee's Social Security Number (SSN).

Enter the employee's address, including street, city, state, and ZIP code.

Enter the employee's name as it appears on their health insurance records.

Enter the employee's Social Security Number (SSN) or Taxpayer Identification Number (TIN).

Enter the employee's address, including street, city, state, and ZIP code.

Enter the employee's name as it appears on their health insurance records.

Enter the employee's Social Security Number (SSN) or Taxpayer Identification Number (TIN).

Enter the employee's Social Security Number (SSN). This field has a maximum length of 11 characters.

Enter the employee's Social Security Number (SSN). This field can contain up to 11 characters.

Enter the employee's Social Security Number (SSN). This field can contain up to 11 characters.

Enter the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage that provides minimum value.

Enter the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage that provides minimum value for the month of March.

Enter the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage that provides minimum value for the month of April.

Enter the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage that provides minimum value.

Enter the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage that provides minimum value for the month of February.

Enter the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage that provides minimum value for the month of March. The value should not exceed 11 characters.

Enter the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage that provides minimum value for the month of April.

Enter the employee's share of the lowest-cost monthly premium for self-only minimum essential coverage providing minimum value that is offered to the employee. This should be a numeric value up to 11 characters.

Check this box if the employee was not a full-time employee for the month.

Enter the street address of the employer, including room or suite number if applicable.

Enter the name of the employer providing the health insurance coverage.

Enter the Employer Identification Number (EIN) of the employer. Maximum length is 10 characters.

Enter the contact telephone number of the employer.

Enter the city or town where the employer is located.

Enter the state or province where the employer is located.

Enter the country and ZIP or foreign postal code where the employer is located.

Enter the employer's name as registered with the IRS.

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

Enter the employer's address, including street, city, state, and ZIP code.

Enter the employer's name as it appears on the health insurance records.

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

Enter the employer's address, including street, city, state, and ZIP code.

Enter the employer's name as it appears on the health insurance records.

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

Enter the address of the employer, including street, city, state, and ZIP code.

Enter the contact phone number for the employer.

Enter the employer's identification number (EIN).

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

Check this box if the employer was eligible for multiemployer interim rule relief for the month.

Check this box if the employer was eligible for section 4980H transition relief for the month.

Check this box if the form is applicable for the current tax year.

Check this box if the form is not applicable for the current tax year.

Enter the code for the offer of coverage for April. This code indicates the type of health insurance coverage offered by your employer for this month.

Enter the code for the offer of coverage for August. This code indicates the type of health insurance coverage offered by your employer for this month.

Enter the code for the offer of coverage for February. This code indicates the type of health insurance coverage offered by your employer for this month.

Enter the code for the offer of coverage for January. This code indicates the type of health insurance coverage offered by your employer for this month.

Enter the code for the offer of coverage for July. This code indicates the type of health insurance coverage offered by your employer for this month.

Enter the code for the offer of coverage for June. This code indicates the type of health insurance coverage offered by your employer for this month.

Enter the code for the offer of coverage for March. This code indicates the type of health insurance coverage offered by your employer for this month.

Enter the code for the offer of coverage for May. This code indicates the type of health insurance coverage offered by your employer for this month.

Enter the code for the offer of coverage for October. This code indicates the type of health insurance coverage offered by your employer for this month.

Enter the code for the offer of coverage for September. This code indicates the type of health insurance coverage offered by your employer for this month.