Instructions For Forms 1094-B And 1095-B - 2017 (Page 7 of 7) in pdf

Part II—Information About Certain

If there are more than six covered individuals, complete

this information for the additional covered individuals on

Employer-Sponsored Coverage

Part IV, Continuation Sheet(s). Do not count the

This part is completed only by issuers or carriers of

continuation sheet(s) as additional Forms 1095-B in the

insured group health plans, including coverage purchased

count of forms submitted with the accompanying Form

through the SHOP.

1094-B.

Insurance companies entering codes A or B on

Privacy Act and Paperwork Reduction Act Notice.

line 8 will complete Part II. Employers reporting

TIP

We ask for the information on these forms to carry out the

self-insured group health plan coverage on Form

Internal Revenue laws of the United States and the

1095-B enter code B on line 8, but don't complete Part II.

Patient Protection and Affordable Care Act. Our legal right

If you entered code B for self-insured coverage, skip Part

to ask for the information on this form is Internal Revenue

II and go to Part III.

Code section 6055 and its regulations. We request it to

Lines 10–15. Enter the name, EIN, and complete mailing

confirm that insured individuals are covered by minimum

address for the employer sponsoring the coverage. If mail

essential coverage and therefore aren't liable for the

isn't delivered to the street address and the employer has

individual shared responsibility payment. If you don't

a P.O. box, enter the box number instead of the street

provide this information, we may be unable to determine

address. See Statements Furnished to Individuals, earlier,

whether covered individuals are liable for the individual

for information on truncating the employer's EIN. If the

shared responsibility payment; providing false or

employer is a member of a controlled group, enter

fraudulent information may subject you to penalties. We

information for the specific controlled group member that

may disclose this information to the Department of Justice

is the covered employee’s employer. If the coverage is

for civil or criminal investigation, and to cities, states, and

provided through an association or a Multiple Employer

the District of Columbia for use in administering their tax

Welfare Arrangement, enter information for the

laws. We may also disclose this information to other

participating employer of the covered employee. Don't

countries under a tax treaty, to Federal and state agencies

complete Part II if the coverage is provided through a

to enforce Federal nontax criminal laws, or to Federal law

multiemployer plan.

enforcement and intelligence agencies to combat

terrorism.

Part III—Issuer or Other Coverage Provider

You aren't required to provide the information

Lines 16–22. Enter your name, EIN, and complete

requested on a form that is subject to the Paperwork

mailing address. The provider of the coverage is the

Reduction Act unless the form displays a valid OMB

issuer or carrier of insured coverage, sponsor of a

control number. Books or records relating to a form or its

self-insured employer plan, government agency providing

instructions must be retained as long as their contents

government-sponsored coverage, or other coverage

may become material in the administration of any Internal

sponsor. Enter on line 18 the telephone number that an

Revenue law. Generally, tax returns and return

individual seeking additional information may call to speak

information are confidential, as required by section 6103.

to a person.

The time needed to complete the following forms will

Part IV—Covered Individuals

vary depending on individual circumstances. The

estimated average time is:

Column (a). Enter the name of each covered individual.

Column (b). Enter the nine-digit SSN or other TIN for

Form 1094-B

10 min.

. . . . . . . . . . . . . . .

each covered individual (111-11-1111). The field may be

Form 1095-B

1 min.

left blank if the covered individual doesn’t have a TIN. See

. . . . . . . . . . . . . . .

Statements Furnished to Individuals, earlier, for

information on truncating the SSN or other TIN.

If you have comments concerning the accuracy of

Column (c). Enter a date of birth (YYYY/MM/DD) for the

these time estimates or suggestions for making this form

covered individual only if an SSN or other TIN isn't

simpler, we would be happy to hear from you. You can

entered in column (b).

send us comments from IRS.gov/FormComments. Or you

Column (d). Check this box if the individual was covered

can write to the Internal Revenue Service, Tax Forms and

for at least one day per month for all 12 months of the

Publications Division, 1111 Constitution Ave. NW,

calendar year.

IR-6526, Washington, DC 20224. Don't send the form to

this office.

Column (e). If the individual wasn't covered for all 12

months, check the applicable box(es) for the months in

which the individual was covered for at least one day.

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Instructions for Forms 1094-B and 1095-B (2017)

Instructions For Forms 1094-B And 1095-B - 2017 Page 7

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