Form 1094-C Form 1094-C Transmittal of Employer-Provided Health Insurance Offer

120117

1094-C

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

Form

Department of the Treasury
Internal Revenue Service

Part I

▶ Information

OMB No. 1545-2251

CORRECTED

2016

about Form 1094-C and its separate instructions is at www.irs.gov/form1094c

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.)

For Official Use Only

12 City or town

13 State or province

14 Country and ZIP or foreign postal code

15 Name of person to contact

17 Reserved .

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18 Total number of Forms 1095-C submitted with this transmittal

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19 Is this the authoritative transmittal for this ALE Member? If “Yes,” check the box and continue. If “No,” see instructions

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Part II

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16 Contact telephone number

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▶

ALE Member Information

20 Total number of Forms 1095-C filed by and/or on behalf of ALE Member .

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21 Is ALE Member a member of an Aggregated ALE Group?

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Yes

No

If “No,” do not complete Part IV.
22 Certifications of Eligibility (select all that apply):
A. Qualifying Offer Method

B. Reserved

C. Section 4980H Transition Relief

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.
▲

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Signature

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Title
Cat. No. 61571A

Date
Form 1094-C (2016)

120217
Page 2

Form 1094-C (2016)

Part III

ALE Member Information—Monthly
(a) Minimum Essential Coverage
Offer Indicator
Yes

23

No

(b) Section 4980H Full-Time
Employee Count for ALE Member

(c) Total Employee Count
for ALE Member

(d) Aggregated
Group Indicator

(e) Section 4980H
Transition Relief Indicator

All 12 Months

24

Jan

25

Feb

26

Mar

27

Apr

28

May

29

June

30

July

31

Aug

32

Sept

33

Oct

34

Nov

35

Dec
Form 1094-C (2016)

120316
Page 3

Form 1094-C (2016)

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

Name

36

51

37

52

38

53

39

54

40

55

41

56

42

57

43

58

44

59

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60

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61

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62

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63

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64

50

65

EIN

Form 1094-C (2016)