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                                                                                                                                               OMB No. 1545-2252
Form 1094-B                                      Transmittal of Health Coverage Information Returns 

Department of the Treasury                       Go to www.irs.gov/Form1094B for instructions and the latest information.                      2023
Internal Revenue Service
1   Filer’s name                                                                                   2   Employer identification number (EIN)

3   Name of person to contact                                                                      4   Contact telephone number

5   Street address (including room or suite no.)                               6   City or town

                                                                                                                                           For Official Use Only
7   State or province                                                          8   Country and ZIP or foreign postal code

9   Total number of Forms 1095-B submitted with this transmittal  . . . . . .  . . . .         . . . . .
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. 61570P       Form 1094-B (2023)