Form 1095-C 2015 - Employer-Provided Health Insurance Offer And Coverage

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600116
VOID
1095-C
Employer-Provided Health Insurance Offer and Coverage
OMB No. 1545-2251
Form
2015
CORRECTED
Department of the Treasury
Information about Form 1095-C and its separate instructions is at
▶
Internal Revenue Service
Part I
Employee
Applicable Large Employer Member (Employer)
1 Name of employee
2 Social security number (SSN)
7 Name of employer
8 Employer identification number (EIN)
3 Street address (including apartment no.)
9 Street address (including room or suite no.)
10 Contact telephone number
5 State or province
11 City or town
12 State or province
13 Country and ZIP or foreign postal code
4 City or town
6 Country and ZIP or foreign postal code
Employee Offer and Coverage
Plan Start Month
Part II
(Enter 2-digit number):
All 12 Months
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
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)
Covered Individuals
Part III
If Employer provided self-insured coverage, check the box and enter the information for each covered individual.
(e) Months of Coverage
(c) DOB (If SSN is
(d) Covered
(a) Name of covered individual(s)
(b) SSN
not available)
all 12 months
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
17
18
19
20
21
22
1095-C
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form
(2015)
Cat. No. 60705M

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