Form 1095-C Template

Use this form to record an employer-provided health insurance offer and coverage information for an employee.

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

Why use a Form 1095-C?

A Form 1095-C helps organize employee, employer, offer-of-coverage, contribution, relief code, and coverage details.

Document coverage offers

Record monthly offer-of-coverage codes and required employee contributions.
Identify employee and employer

Keep employee and applicable large employer details in one structured form.
Support recipient records

Provide coverage information the employee can keep for records and tax reference.

This template covers employee details, employer information, monthly offer codes, contribution fields, and coverage records.

Employee information
Fields capture employee name, SSN, address, and related identifying details.
Employer information
Includes employer name, EIN, address, and contact telephone number fields.
Offer of coverage table
Provides monthly fields for offer codes, required contribution amounts, and relief codes.
Plan and age fields
Includes employee age on January 1, plan start month, and all-12-months fields.
Recipient instructions
Includes instructions on ACA coverage offers, premium tax credit, and recordkeeping.