IRS · Official form

Form 1095-C, Employer-Provided Health Insurance Offer and Coverage

Form 1095-C records the health coverage a large employer offered one employee, month by month. Fill in the official IRS PDF below and download it.

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What is 1095-C?

Form 1095-C, Employer-Provided Health Insurance Offer and Coverage, is filed by Applicable Large Employers for each employee who was full-time for at least one month of the year. It uses offer-of-coverage codes to show what was offered each month, the employee’s share of the lowest cost premium, and any safe harbor the employer relied on.

Employees receive a copy and the IRS gets one too, filed under transmittal Form 1094-C. If the employer’s plan is self-insured, Part III also lists everyone actually covered, which takes the place of a separate Form 1095-B.

Who files 1095-C?

Applicable Large Employers, generally those with 50 or more full-time employees including full-time equivalents
Each ALE member files for every employee who was full-time for one or more months
Self-insured ALEs, who also complete Part III for covered individuals
Payroll providers and benefits administrators preparing the forms for employers

How to fill out 1095-C

Fill in the employee’s name, SSN, and address in Part I, along with the employer’s name, EIN, and contact details.
Enter the offer-of-coverage code for each month on line 14, or use the all-12-months column if the offer never changed.
Complete line 15 with the employee’s required contribution where a code calls for it, and line 16 with any applicable safe harbor code.
For self-insured plans, list each covered individual in Part III and mark their months of coverage.
Download the finished PDF. Furnish the employee copy by the annual deadline and file the IRS copies with Form 1094-C.

Worth knowing: Most employers must file Forms 1094-C and 1095-C with the IRS electronically through the AIR system; paper filing is allowed only for very small filers. Check the current instructions at irs.gov before mailing anything.

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Page 1 71 fields

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CORRECTED

Part I. Employee. 1. Name of employee. First name.

1. Middle initial.

1. Last name.

2 Social security number (SSN)

3 Street address (including apartment no.)

4 City or town

5 State or province

6 Country and ZIP or foreign postal code

7 Name of employer

8 Employer identification number (EIN)

9 Street address (including room or suite no.)

10 Contact telephone number

11 City or town

12 State or province

13 Country and ZIP or foreign postal code

Employee’s Age on January 1

Plan Start Month (enter 2-digit number):

Row: 14. Offer of Coverage (enter required code). Column: All 12 Months.

Row: 14. Offer of Coverage (enter required code). Column: Jan.

Row: 14. Offer of Coverage (enter required code). Column: Feb.

Row: 14. Offer of Coverage (enter required code). Column: Mar.

Row: 14. Offer of Coverage (enter required code). Column: Apr.

Row: 14. Offer of Coverage (enter required code). Column: May.

Row: 14. Offer of Coverage (enter required code). Column: June.

Row: 14. Offer of Coverage (enter required code). Column: July.

Row: 14. Offer of Coverage (enter required code). Column: Aug.

Row: 14. Offer of Coverage (enter required code). Column: Sept.

Row: 14. Offer of Coverage (enter required code). Column: Oct.

Row: 14. Offer of Coverage (enter required code). Column: Nov.

Row: 14. Offer of Coverage (enter required code). Column: Dec.

Row: 15. Employee Required Contribution (see instructions). Column: All 12 Months

Row: 15. Employee Required Contribution (see instructions). Column: Jan

Row: 15. Employee Required Contribution (see instructions). Column: Feb

Row: 15. Employee Required Contribution (see instructions). Column: Mar

Row: 15. Employee Required Contribution (see instructions). Column: Apr

Row: 15. Employee Required Contribution (see instructions). Column: May

Row: 15. Employee Required Contribution (see instructions). Column: June

Row: 15. Employee Required Contribution (see instructions). Column: July

Row: 15. Employee Required Contribution (see instructions). Column: Aug

Row: 15. Employee Required Contribution (see instructions). Column: Sept

Row: 15. Employee Required Contribution (see instructions). Column: Oct

Row: 15. Employee Required Contribution (see instructions). Column: Nov

Row: 15. Employee Required Contribution (see instructions). Column: Dec

Row: 16. Section 4980H Safe Harbor and Other Relief (enter code, if applicable). Column: All 12 Months.

Row: 16. Section 4980H Safe Harbor and Other Relief (enter code, if applicable). Column: Jan.

Row: 16. Section 4980H Safe Harbor and Other Relief (enter code, if applicable). Column: Feb.

Row: 16. Section 4980H Safe Harbor and Other Relief (enter code, if applicable). Column: Mar.

Row: 16. Section 4980H Safe Harbor and Other Relief (enter code, if applicable). Column: Apr.

Row: 16. Section 4980H Safe Harbor and Other Relief (enter code, if applicable). Column: May.

Row: 16. Section 4980H Safe Harbor and Other Relief (enter code, if applicable). Column: June.

Row: 16. Section 4980H Safe Harbor and Other Relief (enter code, if applicable). Column: July.

Row: 16. Section 4980H Safe Harbor and Other Relief (enter code, if applicable). Column: Aug.

Row: 16. Section 4980H Safe Harbor and Other Relief (enter code, if applicable). Column: Sept.

Row: 16. Section 4980H Safe Harbor and Other Relief (enter code, if applicable). Column: Oct.

Row: 16. Section 4980H Safe Harbor and Other Relief (enter code, if applicable). Column: Nov.

Row: 16. Section 4980H Safe Harbor and Other Relief (enter code, if applicable). Column: Dec.

Row: 17. Z I P Code. Column: All 12 Months.

Row: 17. Z I P Code. Column: Jan.

Row: 17. Z I P Code. Column: Feb.

Row: 17. Z I P Code. Column: Mar.

Row: 17. Z I P Code. Column: Apr.

Row: 17. Z I P Code. Column: May.

Row: 17. Z I P Code. Column: June.

Row: 17. Z I P Code. Column: July.

Row: 17. Z I P Code. Column: Aug.

Row: 17. Z I P Code. Column: Sept.

Row: 17. Z I P Code. Column: Oct.

Row: 17. Z I P Code. Column: Nov.

Row: 17. Z I P Code. Column: Dec.

Page 3 235 fields

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Frequently asked questions

Do employees file Form 1095-C with their tax return?

No. Employees keep it for their records. It can help answer coverage questions and matters if anyone in the household also had Marketplace coverage with a premium tax credit.

What are the codes on lines 14 and 16?

Line 14 codes describe what coverage was offered, to whom, and whether it was affordable. Line 16 codes explain the employer’s position, such as the employee not being employed that month or an affordability safe harbor. The full code list is in the Form 1094-C and 1095-C instructions.

When is Part III used?

Only when the employer self-insures the plan. In that case Part III lists each person actually enrolled, so a separate Form 1095-B is not needed for them.

Form 1095-C, Employer-Provided Health Insurance Offer and Coverage

What is 1095-C?

Who files 1095-C?

How to fill out 1095-C

Quick fill 1095-C on this page

Frequently asked questions

Related forms

Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns

Form 1095-B, Health Coverage

Form 8962, Premium Tax Credit (PTC)