Transcription of 2015 Form 1095-C - irs.gov
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2015 Form 1095-C - irs.gov
600116 VOIDCORRECTEDForm 1095-CDepartment of the Treasury Internal Revenue ServiceEmployer-Provided Health Insurance Offer and Coverage Information about Form 1095-C and its separate instructions is at No. 1545-22512015 Part IEmployee 1 Name of employee 2 Social security number (SSN) 3 Street address (including apartment no.) 4 City or town5 State or province 6 Country and ZIP or foreign postal codeApplicable Large Employer Member (Employer) 7 Name of employer 8 Employer identification number (EIN) 9 Street address (including room or suite no.) 10 Contact telephone number11 City or town12 State or province13 Country and ZIP or foreign postal codePart IIEmployee Offer and CoveragePlan Start Month (Enter 2-digit number):All 12 MonthsJanFebMarAprMayJuneJulyAugSeptOctN ovDec14 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)Part IIIC overed Individuals If Employer provided self-insured coverage, check the box and enter the information for each covered individual.
You are receiving this Form 1095-C because your employer is an Applicable Large Employer subject to the employer shared responsibility provision in the Affordable Care Act.
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