33
1095-BCBLK
First-Class Mail
Important Tax Return Document Enclosed
PS1095BCBLK
FROM:
PS1095BC500BLK
14035
PS1095C500
PS1095C
First-Class Mail
Important Tax Document Enclosed
FROM:
600120
Form 1095-C
Department of the Treasury 
Internal Revenue Service
Employer-Provided Health Insurance Offer and Coverage 
 Do not attach to your tax return. Keep for your records.
 Go to www.irs.gov/Form1095C for instructions and the latest information.
VOID
CORRECTED
OMB No. 1545-2251
Part I
Employee 
1  Name of employee (first name, middle initial, last name)
 2  Social security number (SSN)
  3  Street address (including apartment no.) 
  4  City or town
5  State or province
 6 Country and ZIP or foreign postal code
Applicable Large Employer Member (Employer)
 7  Name of employer 
 8 
 9  Street address (including room or suite no.) 
10 Contact telephone number
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 
RAA #1607  For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
41-0852411
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) 
First name, middle initial, last name
(b) SSN or other TIN
(c) DOB (if SSN or other 
TIN is not available)
(d) Covered 
all 12 months
(e) Months of coverage 
     
     
     
     
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
2025
Form 1095-C (2025) Created 5/21/25
PS1095B500
PS1095B
First-Class Mail
Important 
FROM:
Tax Document Enclosed
Form 1095-B
Department of the Treasury  
Internal Revenue Service
Health Coverage
 Do not attach to your tax return. Keep for your records.
 Go to www.irs.gov/Form1095B for instructions and the latest information.
OMB No. 1545-2252
560118
VOID
CORRECTED
Part I
  Responsible Individual
1    Name of responsible individual–First name, middle name, last name
2   Social security number (SSN) or other TIN
3   Date of birth (if SSN or other TIN is not available)
4   Street address (including apartment no.)
5    City or town
6    State or province
7    Country and ZIP or foreign postal code
8   Enter letter identifying Origin of the Health Coverage (see instructions for codes): 
.
.
.
9    Reserved
Part II
  Information About Certain Employer-Sponsored Coverage (see instructions)
10    Employer name
11    
12   Street address (including room or suite no.)
13    City or town
14    State or province
15    Country and ZIP or foreign postal code
Part III
  Issuer or Other Coverage Provider (see instructions)
16    Name
17 
18    Contact telephone number
19   Street address (including room or suite no.)
20    City or town
21    State or province
22    Country and ZIP or foreign postal code
Part IV
  Covered Individuals (Enter the information for each covered individual.)
(a) Name of covered individual(s) 
First name, middle initial, last name
(b) SSN or other TIN
(c) DOB (if SSN or other 
TIN is not available)
(d) Covered 
all 12 months
(e) Months of coverage
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
      
      
    
    
    
     
   
23
24
25
26
27
28
RAA #1607  For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
41-0852411
29
30
31
32
33
34
35
36
37
38
39
40
2025
Form 1095-B (2025) Created 9/24/25
ACA PRE-PRINTED FORMS
Eccentric
Z – Fold
	 Sheets per pack
	 50	
500	
FORM DESCRIPTION
	 1095-B HEALTH COVERAGE
	 1095B50	
1095B500	
1095-B “Employee/Employer” Copy Health Coverage 
	 N/A	
N1095B500	
1095-B Health Coverage Laser Cut Sheet - Alternate Format
	 1094BT50	
N/A	
1094-B Transmittal Of Health Coverage Information Returns Transmittal for Form 1095-B
	 N/A	
PS1095B500	
14" Pressure Seal EZ-Fold 1095-B Employee’s Copy Health Coverage Bulk Pack
	 1095-C EMPLOYER PROVIDED HEALTH INSURANCE OFFER & COVERAGE
	 1095C50	
1095C500	
1095-C “Employee/Employer” Copy Employer-Provided Health Insurance Offer and Coverage
	 N/A	
N1095C500	
1095-C Employer-Provided Health Insurance Offer and Coverage Laser Cut Sheet - Alternate Format
	 1095CIRS50	
1095CIRS500	
1095-C “IRS” Copy Employer-Provided Health Insurance Offer and Coverage 
	 1094CT50	
N/A	
1094-C Transmittal Of Employer-Provided Health Insurance Offer and Coverage Information Returns for Form 1095C, 
3-Page Form
	 N/A	
PS1095C500	
14" Pressure Seal EZ-Fold 1095-C Employee’s Copy Employer Health Insurance Offer and Coverage Bulk Pack
	 1095-C CONTINUATION
	 1095CIRSC50	
N/A	
 1095-C "IRS" Continuation/Part 3 - Copy Employer-Provided Health Insurance Offer and Coverage
	 1095-B OR C BLANK
	 1095BCBLK50	 1095BCBLK500	
1095-B and/or 1095-C Blank with Printed Backer Instructions
	 N/A	
PS1095BC500BLK	
14" Pressure Seal EZ-Fold 1095-B and/or 1095-C Blank w/Printed Backer Instructions Bulk Pack 
	 SOFTWARE
	 14035	
	
2026 ACA Downloadable Software
77771 or 77772
Laser & Pressure Seal
1095-C
This panel
Contains
1095 Copy B Backer
Information
This panel
Contains
1095 Copy C Backer
Information
600120
Form 1095-C
Department of the Treasury 
Internal Revenue Service
Employer-Provided Health Insurance Offer and Coverage 
 Do not attach to your tax return. Keep for your records.
 Go to www.irs.gov/Form1095C for instructions and the latest information.
VOID
CORRECTED
OMB No. 1545-2251
20
Part I
Employee 
1  Name of employee (first name, middle initial, last name)
 2  Social security number (SSN)
  3  Street address (including apartment no.) 
  4  City or town
5  State or province
 6 Country and ZIP or foreign postal code
Applicable Large Employer Member (Employer)
 7  Name of employer 
 8 
 9  Street address (including room or suite no.) 
10 Contact telephone number
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 
Form 1095-C (2025)
RAA #1607  For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
41-0852411
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) 
First name, middle initial, last name
(b) SSN or other TIN
(c) DOB (if SSN or other 
TIN is not available)
(d) Covered 
all 12 months
(e) Months of coverage 
     
     
     
     
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
18
19
20
21
22
23
25
1095C
Form 1095-C 
1095-B
Form 1095-B
2025
Department of the Treasury  
Internal Revenue Service
Health Coverage
 Do not attach to your tax return. Keep for your records.
 Go to www.irs.gov/Form1095B for instructions and the latest information.
OMB No. 1545-2252
560118
VOID
CORRECTED
Part I
  Responsible Individual
1    Name of responsible individual–First name, middle name, last name
2   Social security number (SSN) or other TIN
3   Date of birth (if SSN or other TIN is not available)
4   Street address (including apartment no.)
5    City or town
6    State or province
7    Country and ZIP or foreign postal code
8   Enter letter identifying Origin of the Health Coverage (see instructions for codes): 
.
.
.
9    Reserved
Part II
  Information About Certain Employer-Sponsored Coverage (see instructions)
10    Employer name
11    
12   Street address (including room or suite no.)
13    City or town
14    State or province
15    Country and ZIP or foreign postal code
Part III
  Issuer or Other Coverage Provider (see instructions)
16    Name
17 
18    Contact telephone number
19   Street address (including room or suite no.)
20    City or town
21    State or province
22    Country and ZIP or foreign postal code
Part IV
  Covered Individuals (Enter the information for each covered individual.)
(a) Name of covered individual(s) 
First name, middle initial, last name
(b) SSN or other TIN
(c) DOB (if SSN or other 
TIN is not available)
(d) Covered 
all 12 months
(e) Months of coverage
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
      
      
    
    
    
     
   
23
24
25
26
27
28
RAA #1607  For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Fold 
Here
Form 1095-B (2025) Created 9/24/25
41-0852411
1095B
Employer Name
Employer Address Line 1
Employer Address Line 2
Employer Address Line 3
Policy Holder Name
Policy Holder Address Line 1
Policy Holder Address Line 2
Policy Holder Address Line 3
Catalog images may not reflect official IRS revisions at the time of publication. Final products will be in compliance with official IRS revisions.

View this content as a flipbook by clicking here.