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

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

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The Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns Form 1094-C form is 3 pages long and contains:

  • 1 signature
  • 48 check-boxes
  • 119 other fields

Country of origin: US
File type: PDF

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120118
CORRECTED
Form1094-C
Department of the Treasury
Internal Revenue Service
Transmittal of Employer-Provided Health Insurance Offer and
Coverage Information Returns
▶
Go to www.irs.gov/Form1094C for instructions and the latest information.
OMB No. 1545-2251
2018
Part I
Applicable 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 town 5 State or province
6 Country and ZIP or foreign postal code
7 Name of person to contact 8 Contact telephone number
9 Name of Designated Government Entity (only if applicable)
10 Employer identification number (EIN)
11 Street address (including room or suite no.)
12 City or town 13 State or province
14 Country and ZIP or foreign postal code
15 Name of person to contact 16 Contact telephone number
For Official Use Only
17 Reserved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18 Total number of Forms 1095-C submitted with this transmittal . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
▶
Part II
ALE Member Information
19 Is this the authoritative transmittal for this ALE Member? If “Yes,” check the box and continue. If “No,” see instructions . . . . . . . . . . . . . . . .
20 Total number of Forms 1095-C filed by and/or on behalf of ALE Member . . . . . . . . . . . . . . . . . . . . . . . . . .
▶
21 Is ALE Member a member of an Aggregated ALE Group? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
If “No,” do not complete Part IV.
22 Certifications of Eligibility (select all that apply):
A. Qualifying Offer Method B. Reserved C. Reserved D. 98% Offer Method
Under penalties of perjury, I declare that I have examined this return and accompanying documents, and to the best of my knowledge and belief, they are true, correct, and complete.
▲
Signature
▲
Title
▲
Date
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 61571A
Form 1094-C (2018)
click to sign
signature
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dd mmm yyyy
120218
Form 1094-C (2018) Page 2
Part III
ALE Member Information—Monthly
(a) Minimum Essential Coverage
Offer Indicator
Yes No
(b) Section 4980H Full-Time
Employee Count for ALE Member
(c) Total Employee Count
for ALE Member
(d) Aggregated
Group Indicator
(e) Reserved
23 All 12 Months
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Jan
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Dec
Form 1094-C (2018)
120316
Form 1094-C (2018) Page 3
Part IV
Other ALE Members of Aggregated ALE Group
Enter the names and EINs of Other ALE Members of the Aggregated ALE Group (who were members at any time during the calendar year).
Name EIN
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Name EIN
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Form 1094-C (2018)
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Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns Form 1094-C

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Completed 23 May 2019

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