Form 1095-C Generator by Jotform
Applicable large employers use Form 1095-C to report the health coverage they offered full-time employees. Fill out each employee's Form 1095-C online for free with Jotform and download a completed PDF in the official IRS layout.
Protect employee information
Form 1095-C lists employee names, Social Security numbers, and details about covered family members. Jotform keeps that data safe with 256-bit SSL encryption and GDPR and CCPA friendly features. For extra protection, you can switch on encrypted forms.
Work from any device
HR and payroll staff can fill out Form 1095-C on a desktop, laptop, tablet, or phone. The form adjusts to each screen, so nobody's stuck waiting to get back to their desk.
Fill in codes and download a PDF
Enter offer codes, required contributions, and safe harbor codes in clear, labeled fields. Then download each completed Form 1095-C as a PDF to share with employees or keep in your records.
Formatted like the IRS original
Jotform converts every submission into the original IRS Form 1095-C layout, so the statements you hand out look exactly like the official form.
FAQ
What is Form 1095-C?
Form 1095-C, Employer-Provided Health Insurance Offer and Coverage, reports whether an employer offered health coverage to a full-time employee and their dependents and what the cheapest coverage option would have cost the employee. For self-insured plans, it also shows who was covered each month.
It's part of the employer reporting rules under the Affordable Care Act.
Which employers have to file Form 1095-C?
Applicable large employers (ALEs), generally those with 50 or more full-time employees, including full-time equivalents, in the prior year, file Form 1095-C for each full-time employee.
ALEs with self-insured plans also use Part III to report coverage for anyone who enrolled, including employees who weren't full time.
When is Form 1095-C due?
Employers give Form 1095-C to employees early in the year and file copies with the IRS, along with the Form 1094-C transmittal, by deadlines that differ for paper and electronic filing. Many employers must file electronically.
Deadlines and furnishing rules have changed in recent years, so check the current IRS instructions before you send anything.
Do employees file Form 1095-C with their tax return?
No. Employees don't attach Form 1095-C to their return. They should keep it with their tax records, and it can help them figure out whether they qualify for the premium tax credit.
How do I fill out Form 1095-C?
In Part I, enter the employee's name, Social Security number, and address, along with your company's name, EIN, address, and contact phone number. Part II covers the offer of coverage: the employee's age on January 1, the plan start month, and then month-by-month entries for the offer code on line 14, the employee's required contribution on line 15, and a safe harbor or relief code on line 16. Line 17 asks for a ZIP code in certain cases.
If you sponsor a self-insured plan, list each covered individual and the months they had coverage in Part III.
Can I create Form 1095-C for free with Jotform?
Yes. You can fill out Form 1095-C and download it as a PDF at no cost. Jotform doesn't file the forms with the IRS, so you'll still handle IRS filing yourself or through your payroll provider.
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