2015 Form 1095-B - Health Coverage
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3560115
1095-B
VOID
OMB No. 1545-2252
Health Coverage
Form
2015
CORRECTED
Department of the Treasury
Information about Form 1095-B and its separate instructions is at
▶
Internal Revenue Service
Part I
Responsible Individual
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2 Social security number (SSN)
3 Date of birth (If SSN is not available)
Name of responsible individual
4 Street address (including apartment no.)
5
City or town
6
State or province
7
Country and ZIP or foreign postal code
9 Small Business Health Options Program (SHOP) Marketplace identifier, if applicable
Enter letter identifying Origin of the Policy (see instructions for codes):
.
.
.
.
.
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8
▶
Part II
Employer Sponsored Coverage (see instructions)
10
Employer name
11
Employer identification number (EIN)
12 Street address (including room or suite no.)
13
14
15
City or town
State or province
Country and ZIP or foreign postal code
Part III
Issuer or Other Coverage Provider (see instructions)
16
Name
17
Employer identification number (EIN)
18
Contact telephone number
19 Street address (including room or suite no.)
20
City or town
21
State or province
22
Country and ZIP or foreign postal code
Part IV
Covered Individuals (Enter the information for each covered individual(s).)
(a) Name of covered individual(s)
(b) SSN
(c) DOB (If SSN is not
(d) Covered
(e) Months of coverage
available)
all 12 months
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
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1095-B
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form
(2015)
Cat. No. 60704B
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