Form 1095-B Template

Use this form to record health coverage information for a responsible individual and covered individuals.

By using this template, you agree to our Template Terms of Use.

Why use a Form 1095-B?

A Form 1095-B helps organize responsible individual, employer, coverage provider, and covered individual details.

Record health coverage

Capture minimum essential coverage details for covered individuals and months.
Identify coverage source

Use origin codes and provider fields to show where health coverage came from.
Keep records organized

Provide a form the recipient can keep for records instead of attaching to a tax return.

This template includes responsible individual details, employer coverage information, provider data, and covered persons.

Responsible individual
Fields capture name, TIN or date of birth, address, and origin of coverage code.
Employer-sponsored coverage
Includes employer name, EIN, and address fields for certain employer coverage.
Coverage provider details
Fields capture issuer or provider name, EIN, contact telephone number, and address.
Covered individuals table
Includes names, TINs or dates of birth, full-year coverage, and monthly coverage boxes.
Recipient instructions
Includes instructions on coverage records, premium tax credit notes, and additional ACA information.