FORM 1095-C
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| Part I: Employee Applicable Large Employer Member (ALE Member/Employer) | |||||||||
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| Part III: Covered Individuals |
| Part III Lines 17-22, Covered Individuals |
FORM 1094-C
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| Part II: ALE Member Information |
| Line 20, Total Number of Forms filed by and/or on behalf of the employer. |
| Line 21, ALE Member is part of Aggregated ALE Group |
| Line 22, Certifications of Eligibility |
| Part III: ALE Member Information — Monthly (Lines 23–35) |
| Column (a), Minimum Essential Coverage |
| Column (b), Full-Time Employee Count for ALE Member |
| Column (c), Total Employee Count for ALE Member |
| Column (d), Aggregated Group Indicator |
| Column (e), Aggregated Group Indicator |
| Part IV: Other ALE Members of Aggregated ALE Group |
| Lines 36-65, Other ALE Members of Aggregated ALE Group |
FORM 1095-B
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| Part I: Responsible Individual |
| Part II: Employer-Sponsored Coverage |
| Lines 10-15, Name, EIN, and Complete Mailing Address for the Employer Sponsoring the Coverage |
| Part III: Issuer or Other Coverage Provider |
| Lines 16-22, Name, EIN, and Complete Mailing Address of Issuer/ Other Coverage |
| Part IV: Covered Individuals |
| Column (a), Covered Individual's Name |
| Column (b), Covered Individual's Social Security Number (SSN) |
| Column (c), Covered Individual's Birthdate (MM/DD/YYY) if Social Security Number (SSN) is not available |
| Column (d), Covered all 12 months |
| Column (e), Months of Coverage |
| Part IV: Covered Individuals (Continuation) |
| Column (a), Name of each Covered Individual |
| Column (b), Social Security Number (SSN) of each Covered Individual |
| Column (c), Birthdate (MM/DD/YYY) of each Covered Individual if SSN is not available |
| Column (d), Individual Covered for 12 months |
| Column (e), Coverage each month if individual wasn't covered for all 12 months |
FORM 1094-B
Click on the individual boxes below for specific IRS Instructions.
