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

What Is IRS Form 1094-C?

This is a tax form that was released by the Internal Revenue Service (IRS) - a subdivision of the U.S. Department of the Treasury. Check the official IRS-issued instructions before completing and submitting the form.

Form Details:

  • A 3-page form available for download in PDF;
  • This form cannot be used to file taxes for the current year. Choose a more recent version to file for the current tax year;
  • Editable, printable, and free;

Download a fillable version of IRS Form 1094-C through the link below or browse more documents in our library of IRS Forms.

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

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120118
1094-C
Transmittal of Employer-Provided Health Insurance Offer and
OMB No. 1545-2251
CORRECTED
Form
Coverage Information Returns
2018
Department of the Treasury
Go to www.irs.gov/Form1094C for instructions and the latest information.
Internal Revenue Service
Applicable Large Employer Member (ALE Member)
Part I
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
16 Contact telephone number
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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ALE Member Information
Part II
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?
Yes
No
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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.
1094-C
Cat. No. 61571A
Form
(2018)
120118
1094-C
Transmittal of Employer-Provided Health Insurance Offer and
OMB No. 1545-2251
CORRECTED
Form
Coverage Information Returns
2018
Department of the Treasury
Go to www.irs.gov/Form1094C for instructions and the latest information.
Internal Revenue Service
Applicable Large Employer Member (ALE Member)
Part I
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
16 Contact telephone number
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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ALE Member Information
Part II
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?
Yes
No
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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.
1094-C
Cat. No. 61571A
Form
(2018)
120218
2
Form 1094-C (2018)
Page
Part III
ALE Member Information—Monthly
(a) Minimum Essential Coverage
(b) Section 4980H Full-Time
(c) Total Employee Count
(d) Aggregated
(e) Reserved
Offer Indicator
Employee Count for ALE Member
for ALE Member
Group Indicator
Yes
No
23
All 12 Months
Jan
24
Feb
25
Mar
26
Apr
27
May
28
June
29
July
30
Aug
31
Sept
32
Oct
33
Nov
34
Dec
35
1094-C
Form
(2018)
120316
3
Form 1094-C (2018)
Page
Other ALE Members of Aggregated ALE Group
Part IV
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
EIN
36
51
37
52
38
53
39
54
40
55
41
56
42
57
43
58
44
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45
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49
64
50
65
1094-C
Form
(2018)
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