Form 1095-C, Employer Health Insurance Coverage

The Form 1095-C, Employer-Provided Health Insurance Offer and Coverage skill extracts data from Forms 1095-C, which are used to provide information to employees and the Internal Revenue Service (IRS) about health insurance coverage offered by employers. The Form 1095-C, Employer-Provided Health Insurance Offer and Coverage skill is a preview skill. It has been trained on a limited set of documents and is designed to help you quickly get started with processing Forms 1095-C. For production use, you may need to uptrain the skill with your own document samples. This skill recognizes handwritten text. The option is enabled by default. If you do not import handwritten forms, disable the Handwritten option in the skill settings.

Countries and Languages

Countries	Languages
USA	English

Basic Form Information

Field	Description
Year	The name of the health insurance carrier.
Void	Specifies that the processed form should be annulled.
Corrected	Specifies that the processed form is being submitted to correct data provided earlier.

Part I - Employee and Employer Information

Employee Information

Field	Description
Name of Employee	The name of the covered employee.
Social Security Number	The Social Security Number (SSN) of the covered employee.
Street Address	The address of the covered employee.
City or Town	The address of the covered employee.
State or Province	The address of the covered employee.
Country and ZIP or Foreign Postal Code	The address of the covered employee.

Employer Information

Field	Description
Name of Employer	The name of the employer sponsoring the coverage.
Employer Identification Number	The Employer Identification Number (EIN) of the employer sponsoring the coverage.
Street Address	The address and phone number of the employer sponsoring the coverage.
Contact Telephone Number	The address and phone number of the employer sponsoring the coverage.
City or Town	The address and phone number of the employer sponsoring the coverage.
State or Province	The address and phone number of the employer sponsoring the coverage.
Country and ZIP or Foreign Postal Code	The address and phone number of the employer sponsoring the coverage.

Part II - Coverage Information

General Coverage Details

Field	Description
Employee’s Age on January 1	The age of the employee as of January 1st of the previous calendar year.
Plan Start Month	The month in which the employer’s health insurance plan year begins.

Offer of Coverage Table

Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.

Month	Description
All 12 Months	Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Jan	Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Feb	Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Mar	Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Apr	Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
May	Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
June	Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
July	Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Aug	Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Sept	Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Oct	Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Nov	Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Dec	Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.

Employee Required Contribution Table

Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount.

Month	Description
All 12 Months	Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount.
Jan	Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount.
Feb	Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount.
Mar	Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount.
Apr	Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount.
May	Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount.
June	Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount.
July	Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount.
Aug	Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount.
Sept	Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount.
Oct	Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount.
Nov	Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount.
Dec	Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount.

Section 4980H Safe Harbor and Other Relief Table

Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.

Month	Description
All 12 Months	Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Jan	Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Feb	Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Mar	Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Apr	Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
May	Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
June	Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
July	Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Aug	Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Sept	Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Oct	Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Nov	Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Dec	Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.

ZIP Code Table

Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.

Month	Description
All 12 Months	Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Jan	Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Feb	Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Mar	Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Apr	Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
May	Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
June	Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
July	Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Aug	Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Sept	Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Oct	Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Nov	Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.
Dec	Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.

Part III - Self-Insured Coverage

General Self-Insured Information

Field	Description
Employer Provided Self-Insured Coverage	Indicates that the health insurance coverage offered by the employer was self-insured.

Covered Individuals Table

Field	Description
Name	The name of each covered individual, including the employee, if the employee is enrolled in self-insured coverage.
SSN or TIN	The Social Security Number (SSN) or Taxpayer Identification Number (TIN) for each covered individual.
DOB	The date of birth (YYYY-MM-DD) for the covered individual.
Covered All 12 Months	Indicates that the individual was covered for at least one day per month for all 12 months of the calendar year.

Monthly Coverage Details

Month	Description
Jan	The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year.
Feb	The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year.
Mar	The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year.
Apr	The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year.
May	The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year.
June	The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year.
July	The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year.
Aug	The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year.
Sept	The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year.
Oct	The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year.
Nov	The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year.
Dec	The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year.

Key Fields

Part I/Employee/Name of Employee
Part I/Employee/Social Security Number
Part I/Employer/Name of Employer
Part I/Employer/Employer Identification Number

Validation Rules

Rule	Description
Clean Name	Checks for unsupported characters such as \| and ] in name fields. It also cleans multiple spaces, tabs, and newlines.
Clean Year	Checks the value in the Year field. It converts a 2-digit year (such as 24) into a 4-digit format (such as 2024). It assumes all 2-digit years are in the 2000s.

​Countries and Languages

​Basic Form Information

​Part I - Employee and Employer Information

​Employee Information

​Employer Information

​Part II - Coverage Information

​General Coverage Details

​Offer of Coverage Table

​Employee Required Contribution Table

​Section 4980H Safe Harbor and Other Relief Table

​ZIP Code Table

​Part III - Self-Insured Coverage

​General Self-Insured Information

​Covered Individuals Table

​Monthly Coverage Details

​Key Fields

​Validation Rules