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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.                     2021
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.

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  Signature                                                                          Title                                                  Date

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.                                           Cat. No. 61570P        Form 1094-B (2021)