Form 1094-B Template

Use this form to transmit Forms 1095-B for health coverage information returns.

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Why use a Form 1094-B?

Form 1094-B helps filers submit a clear transmittal for health coverage information returns.

Identify the filer

Capture the filer name, employer identification number, contact person, and phone number.
Summarize submissions

Record the total number of Forms 1095-B submitted with the transmittal.
Certify the return

Provide a signature area for confirming the return and accompanying documents.

This template covers filer information, contact details, submission count, and certification.

Filer details
Fields capture the filer's name and employer identification number for the transmittal.
Contact information
Fields record the contact person's name and telephone number for follow-up.
Mailing address
Address fields cover the street, city, state or province, country, and postal code.
Form 1095-B count
A line records the total number of Forms 1095-B submitted with the form.
Signature block
The certification area includes signature, title, and date fields for completion.