Form 1095-C Draft - Employer-Provided Health Insurance Offer And Covegate - 2017 Page 2

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DRAFT AS OF
600117
VOID
1095-C
Employer-Provided Health Insurance Offer and Coverage
OMB No. 1545-2251
Form
2017
Do not attach to your tax return. Keep for your records.
CORRECTED
▶
Department of the Treasury
August 14, 2017
Go to for instructions and the latest information.
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
DO NOT FILE
4 City or town
5 State or province
6 Country and ZIP or foreign postal code
11 City or town
12 State or province
13 Country and ZIP or foreign postal code
Employee Offer of Coverage
Part II
Plan Start Month
(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
Required
Contribution (see
$
$
$
$
$
$
$
$
$
$
$
$
$
instructions)
16 Section 4980H
Safe Harbor and
Other Relief (enter
code, if applicable)
Part III
Covered Individuals
If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee.
(c) DOB (If SSN
(e) Months of Coverage
(d) Covered
(a) Name of covered individual(s)
(b) SSN or other TIN
or other TIN is
all 12 months
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
not available)
17
18
19
20
21
22
1095-C
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form
(2017)
Cat. No. 60705M

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