600120 

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                                                                                                                                                                             OMB No. 1545-2251
                                        Employer-Provided Health Insurance Offer and Coverage 
Form 1095-C                                                    ▶ Do not attach to your tax return. Keep for your records.                                       CORRECTED
Department of the Treasury 
Internal Revenue Service                              ▶ Go to www.irs.gov/Form1095C for instructions and the latest information.                                                    2021
Part I        Employee                                                                                                   Applicable Large Employer Member (Employer)
1  Name of employee (first name, middle initial, last name)            2Social security number (SSN)          7  Name of employer                                       8  Employer identification number (EIN)

  3  Street address (including apartment no.)                                                                 9  Street address (including room or suite no.)          10 Contact telephone number

  4  City or town                5  State or province               6 Country and ZIP or foreign postal code 11 City or town           12  State or province           13 Country and ZIP or foreign postal code

Part II       Employee Offer of Coverage                                       Employee’s Age on January 1                             Plan Start Month (enter 2-digit number):
                    All 12 Months       Jan                Feb     Mar           Apr                May          June             July   Aug                    Sept   Oct          Nov            Dec
14  Offer of 
Coverage (enter 
required code)
15  Employee 
Required 
Contribution (see 
instructions)       $             $                   $          $             $               $             $               $         $                      $      $     $             $
16 Section 4980H 
Safe Harbor and 
Other Relief (enter 
code, if applicable)

17 ZIP Code 
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.                                                    Cat. No. 60705M                                   Form 1095-C (2021)

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Form 1095-C (2021)                                                                                                                                                                                      Page 2 
                                                                                                          1A. Minimum essential coverage providing minimum value offered to you with an employee required 
Instructions for Recipient                                                                                contribution for self-only coverage equal to or less than 9.5% (as adjusted) of the 48 contiguous states 
You are receiving this Form 1095-C because your employer is an Applicable Large Employer subject to       single federal poverty line and minimum essential coverage offered to your spouse and dependent(s) 
the employer shared responsibility provisions in the Affordable Care Act. This Form 1095-C includes       (referred to here as a Qualifying Offer). This code may be used to report for specific months for which a 
information about the health insurance coverage offered to you by your employer. Form 1095-C, Part        Qualifying Offer was made, even if you did not receive a Qualifying Offer for all 12 months of the 
II, includes information about the coverage, if any, your employer offered to you and your spouse and     calendar year. For information on the adjustment of the 9.5%, visit IRS.gov.
dependent(s). If you purchased health insurance coverage through the Health Insurance Marketplace         1B. Minimum essential coverage providing minimum value offered to you and minimum essential 
and wish to claim the premium tax credit, this information will assist you in determining whether you     coverage NOT offered to your spouse or dependent(s). 
are eligible. For more information about the premium tax credit, see Pub. 974, Premium Tax Credit         1C. Minimum essential coverage providing minimum value offered to you and minimum essential 
(PTC). You may receive multiple Forms 1095-C if you had multiple employers during the year that were      coverage offered to your dependent(s) but NOT your spouse. 
Applicable Large Employers (for example, you left employment with one Applicable Large Employer 
and began a new position of employment with another Applicable Large Employer). In that situation,        1D. Minimum essential coverage providing minimum value offered to you and minimum essential 
each Form 1095-C would have information only about the health insurance coverage offered to you by        coverage offered to your spouse but NOT your dependent(s). 
the employer identified on the form. If your employer is not an Applicable Large Employer, it is not      1E. Minimum essential coverage providing minimum value offered to you and minimum essential 
required to furnish you a Form 1095-C providing information about the health coverage it offered.         coverage offered to your dependent(s) and spouse. 
In addition, if you, or any other individual who is offered health coverage because of their relationship 1F. Minimum essential coverage NOT providing minimum value offered to you, or you and your spouse 
to you (referred to here as family members), enrolled in your employer’s health plan and that plan is a   or dependent(s), or you, your spouse, and dependent(s).  
type of plan referred to as a “self-insured” plan, Form 1095-C, Part III, provides information about you  1G. You were NOT a full-time employee for any month of the calendar year but were enrolled in self-
and your family members who had certain health coverage (referred to as “minimum essential                insured employer-sponsored coverage for one or more months of the calendar year. This code will be 
coverage”) for some or all months during the year. If you or your family members are eligible for certain entered in the All 12 Months box or in the separate monthly boxes for all 12 calendar months on       
types of minimum essential coverage, you may not be eligible for the premium tax credit.                  line 14.
If your employer provided you or a family member health coverage through an insured health plan or        1H. No offer of coverage (you were NOT offered any health coverage or you were offered coverage that 
in another manner, you may receive information about the coverage separately on Form 1095-B,              is NOT minimum essential coverage). 
Health Coverage. Similarly, if you or a family member obtained minimum essential coverage from            1I. Reserved for future use.
another source, such as a government-sponsored program, an individual market plan, or 
miscellaneous coverage designated by the Department of Health and Human Services, you may                 1J. Minimum essential coverage providing minimum value offered to you; minimum essential coverage 
receive information about that coverage on Form 1095-B. If you or a family member enrolled in a           conditionally offered to your spouse; and minimum essential coverage NOT offered to your   
qualified health plan through a Health Insurance Marketplace, the Health Insurance Marketplace will       dependent(s).
report information about that coverage on Form 1095-A, Health Insurance Marketplace Statement.            1K. Minimum essential coverage providing minimum value offered to you; minimum essential coverage 
                                                                                                          conditionally offered to your spouse; and minimum essential coverage offered to your dependent(s).
            Employers are required to furnish Form 1095-C only to the employee. As the recipient of       1L. Individual coverage health reimbursement arrangement (HRA) offered to you only with affordability 
TIP         this Form 1095-C, you should provide a copy to any family members covered under a             determined by using employee’s primary residence ZIP code.
            self-insured employer-sponsored plan listed in Part III if they request it for their records. 1M. Individual coverage HRA offered to you and dependent(s) (not spouse) with affordability 
                                                                                                          determined by using employee’s primary residence ZIP code.
Additional information. For additional information about the tax provisions of the Affordable Care Act    1N. Individual coverage HRA offered to you, spouse, and dependent(s) with affordability determined by 
(ACA), including the individual shared responsibility provisions, the premium tax credit, and the         using employee’s primary residence ZIP code.
employer shared responsibility provisions, visit www.irs.gov/ACA or call the IRS Healthcare Hotline for   1O. Individual coverage HRA offered to you only using the employee’s primary employment site ZIP 
ACA questions (800-919-0452).                                                                             code affordability safe harbor.
Part I. Employee                                                                                          1P. Individual coverage HRA offered to you and dependent(s) (not spouse) using the employee’s 
Lines 1–6. Part I, lines 1 through 6, reports information about you, the employee.                        primary employment site ZIP code affordability safe harbor.
Line 2. This is your social security number (SSN). For your protection, this form may show only the last  1Q. Individual coverage HRA offered to you, spouse, and dependent(s) using the employee’s primary 
four digits of your SSN. However, the employer is required to report your complete SSN to the IRS.        employment site ZIP code affordability safe harbor.
                                                                                                          1R. Individual coverage HRA that is NOT affordable offered to you; employee and spouse or 
Part I. Applicable Large Employer Member (Employer)                                                       dependent(s); or employee, spouse, and dependents.
Lines 7–13. Part I, lines 7 through 13, reports information about your employer.                          1S. Individual coverage HRA offered to an individual who was not a full-time employee.
Line 10. This line includes a telephone number for the person whom you may call if you have questions     1T. Individual coverage HRA offered to employee and spouse (no dependents) with affordability 
about the information reported on the form or to report errors in the information on the form and ask     determined using employee’s primary residence ZIP code.
that they be corrected.                                                                                   1U. Individual coverage HRA offered to employee and spouse (no dependents) using employee’s 
Part II. Employer Offer of Coverage, Lines 14–17                                                          primary employment site ZIP code affordability safe harbor.
Line 14. The codes listed below for line 14 describe the coverage that your employer offered to you       1V. Reserved for future use.
and your spouse and dependent(s), if any. (If you received an offer of coverage through a                 1W. Reserved for future use.
multiemployer plan due to your membership in a union, that offer may not be shown on line 14.)  The       1X. Reserved for future use.
information on line 14 relates to eligibility for coverage subsidized by the premium tax credit for you,  1Y. Reserved for future use.
your spouse, and dependent(s). For more information about the premium tax credit, see Pub. 974.           1Z. Reserved for future use.
                                                                                                                                                                                      (Continued on page 4)

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Form 1095-C (2021)                                                                                                                                                       Page 3
Part III Covered Individuals 
         If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee.
  (a) Name of covered individual(s)                 (b) SSN or other TIN (c) DOB (if SSN or other (d) Covered                       (e) Months of coverage 
  First     name, middle initial,     last name                          TIN is not     available)all 12 months     Jan Feb Mar Apr May June July Aug      Sept Oct  Nov Dec

18

19

20

21

22

23

24

25

26

27

28

29

30
                                                                                                                                                                Form 1095-C (2021)

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Form 1095-C (2021)                                                                                                                                                                                           Page 4
Instructions for Recipient (continued)                                                                   Line 17. This line reports the applicable ZIP code your employer used for determining affordability if 
Line 15. This line reports the employee required contribution, which is the monthly cost to you for the  you were offered an individual coverage HRA. If code 1L, 1M, 1N, or 1T was used on line 14, this will 
lowest cost self-only minimum essential coverage providing minimum value that your employer offered      be your primary residence location. If code 1O, 1P, 1Q, or 1U was used on line 14, this will be your 
you. For an individual coverage HRA, the employee required contribution is the excess of the monthly     primary employment site. For more information about individual coverage HRAs, visit IRS.gov.
premium based on the employee’s applicable age for the applicable lowest cost silver plan over the       Part III. Covered Individuals, Lines 18–30 
monthly individual coverage HRA amount (generally, the annual individual coverage HRA amount             Part III reports the name, SSN (or TIN for covered individuals other than the employee listed in Part I), 
divided by 12). See the Instructions for Forms 1094-C and 1095-C for more details. The amount            and coverage information about each individual (including any full-time employee and non-full-time 
reported on line 15 may not be the amount you paid for coverage if, for example, you chose to enroll in  employee, and any employee’s family members) covered under the employer’s health plan, if the plan 
more expensive coverage such as family coverage. Line 15 will show an amount only if code 1B, 1C,        is “self-insured.” A date of birth will be entered in column (c) only if an SSN (or TIN for covered 
1D, 1E, 1J, 1K, 1L, 1M, 1N, 1O, 1P, 1Q, 1T, or 1U is entered on line 14. If you were offered coverage    individuals other than the employee listed in Part I) is not entered in column (b). Column (d) will be 
but there is no cost to you for the coverage, this line will report  “0.00” for the amount. For more     checked if the individual was covered for at least one day in every month of the year. For individuals 
information, including on how your eligibility for other healthcare arrangements might affect the amount who were covered for some but not all months, information will be entered in column (e) indicating the 
reported on line 15, visit IRS.gov.                                                                      months for which these individuals were covered. If there are more than 13 covered individuals, 
Line 16. This code provides the IRS information to administer the employer shared responsibility         additional copies of page 3 may be used.
provisions. Other than a code 2C, which reflects your enrollment in your employer’s coverage, none of 
this information affects your eligibility for the premium tax credit. For more information about the 
employer shared responsibility provisions, visit IRS.gov.