Form 1094-C Template

Use this form to transmit employer-provided health insurance offer and coverage information returns.

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Why use a Form 1094-C?

Form 1094-C helps ALE Members report employer and coverage return details in one transmittal.

Identify the ALE Member

Capture employer name, EIN, address, contact person, and telephone number.
Report return totals

Record the number of Forms 1095-C filed by or on behalf of the ALE Member.
Document ALE status

Track monthly ALE member counts, full-time employees, and aggregated group details.

This template covers ALE Member details, transmittal totals, monthly information, and certification.

ALE Member details
Fields capture employer name, EIN, address, contact person, and telephone number.
Government entity details
Optional fields capture designated government entity information when applicable.
Transmittal totals
Lines record Forms 1095-C submitted and whether the filing is the authoritative transmittal.
Eligibility certifications
Checkboxes capture available certification options, including qualifying offer and 98% offer methods.
Monthly ALE data
Part III records monthly full-time employee counts and total employee counts.
Aggregated group members
Part IV lists other ALE Members when the employer is part of an aggregated group.