Department of the Treasury
Internal Revenue Service
Information about Form 1095-B and its separate instructions is at www.irs.gov/form1095b.
OMB No. 1545-2252
1 Name of responsible individual 2 Social security number (SSN) 3 Date of birth (If SSN is not available)
4 Street address (including apartment no.) 5 City or town 6 State or province 7 Country and ZIP or foreign postal code
9 Small Business Health Options Program (SHOP) Marketplace identifier, if applicable
Employer Sponsored Coverage (see instructions)
10 Employer name 11 Employer identification number (EIN)
12 Street address (including room or suite no.) 13 City or town 14 State or province 15 Country and ZIP or foreign postal code
Issuer or Other Coverage Provider (see instructions)
16 Name 17 Employer identification number (EIN) 18 Contact telephone number
19 Street address (including room or suite no.) 20 City or town 21 State or province 22 Country and ZIP or foreign postal code
Covered Individuals (Enter the information for each covered individual(s).)
(a) Name of covered individual(s) (b) SSN (c)
DOB (If SSN is not
all 12 months
(e) Months of coverage
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 60704B
Form 1095-B (2015)
Enter letter identifying Origin of the Policy (see instructions for codes): . . . . . .