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2019 Form 1094-C - IRS tax forms

120118 CORRECTEDForm1094-CDepartment of the Treasury Internal Revenue ServiceTransmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns Go to for instructions and the latest No. 1545-22512019 Part IApplicable Large Employer Member (ALE Member)1 Name of ALE Member (Employer) 2 Employer identification number (EIN)3 Street address (including room or suite no.)4 City or town5 State or province6 Country and ZIP or foreign postal code7 Name of person to contact8 Contact telephone number9 Name of Designated Government Entity (only if applicable) 10 Employer identification number (EIN)11 Street address (including room or suite no.)

120218. Form 1094-C (2019) Page . 2. Part III ALE Member Information—Monthly (a) Minimum Essential Coverage Offer Indicator . Yes. No (b) Section 4980H Full-Time

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