ILMA Compoundings November 2016 - 26

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must be furnished to the IRS and the employee. Additionally, a
company must complete and submit a revised 1094-C to the IRS
if there was an error in the employer identification number.

120117

Form

1094-C

Transmittal of Employer-Provided Health Insurance Offer and
Coverage Information Returns

Department of the Treasury
Internal Revenue Service

▶ Information

OMB No. 1545-2251

CORRECTED

2016

about Form 1094-C and its separate instructions is at www.irs.gov/form1094c

Applicable Large Employer Member (ALE Member)

Part I

1 Name of ALE Member (Employer)

2 Employer identification number (EIN)

3 Street address (including room or suite no.)

1094-C "Authoritative Transmittal"
Also clarified for 2016 reporting, an ALE must specifically
identify and mark one 1094-C as the "authoritative transmittal"
if that employer opts to submit multiple 1094-C forms. If, in the
alternative, the employer elects to provide only one 1094-C to
the IRS with all 1095-C forms, then the employer should indicate
that sole 1094-C to be the authoritative transmittal.

How to Report COBRA Coverage

8 Contact telephone number

9 Name of Designated Government Entity (only if applicable)

For Official Use Only

12 City or town

13 State or province

14 Country and ZIP or foreign postal code

15 Name of person to contact

17 Reserved .

16 Contact telephone number

18 Total number of Forms 1095-C submitted with this transmittal

19 Is this the authoritative transmittal for this ALE Member? If "Yes," check the box and continue. If "No," see instructions

▶

ALE Member Information

Part II

20 Total number of Forms 1095-C filed by and/or on behalf of ALE Member .

▶

21 Is ALE Member a member of an Aggregated ALE Group?

Yes

If "No," do not complete Part IV.
22 Certifications of Eligibility (select all that apply):
A. Qualifying Offer Method

B. Reserved

C. Section 4980H Transition Relief

D. 98% Offer Method

Under penalties of perjury, I declare that I have examined this return and accompanying documents, and to the best of my knowledge and belief, they are true, correct, and complete.
▲

▲

Signature

Title

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

1095-C

Part I

▶ Information

Form 1094-C (2016)

Employee

600116

VOID

OMB No. 1545-2251

CORRECTED

about Form 1095-C and its separate instructions is at www.irs.gov/form1095c

Applicable Large Employer Member (Employer)

1 Name of employee

2 Social security number (SSN)

3 Street address (including apartment no.)
5 State or province

4 City or town

Date

Cat. No. 61571A

Employer-Provided Health Insurance Offer and Coverage

Form
Department of the Treasury
Internal Revenue Service

Jan

2015

7 Name of employer

8 Employer identification number (EIN)

9 Street address (including room or suite no.)

10 Contact telephone number

6 Country and ZIP or foreign postal code 11 City or town

12 State or province

13 Country and ZIP or foreign postal code

Plan Start Month (Enter 2-digit number):

Employee Offer and Coverage
All 12 Months

Given the specificity of the reporting requirements and the
revisions made for the 2016 instructions and forms, it may be
advisable to consult with the company's tax adviser regarding
the affirmative obligations that the ACA may impose upon the
business.

10 Employer identification number (EIN)

11 Street address (including room or suite no.)

Part II

Conclusion

6 Country and ZIP or foreign postal code

5 State or province

7 Name of person to contact

▲

If an employee is offered health coverage under the
Comprehensive Omnibus Budget Reconciliation Act (COBRA),
the draft instructions provide new guidance as well. If an
employer extends an offer to COBRA coverage to an employee
who was terminated, the guidance states that it should not be
reported as an offer of coverage on line 14 of the form. Instead,
Code 1H (no offer of coverage) must be entered on line 14,
and code 2A must be placed on line 16. This is the required
procedure regardless of whether the employee elects to enroll
in the COBRA coverage.

4 City or town

Feb

Mar

Apr

May

June

July

Aug

Sept

Oct

Nov

Dec

14 Offer of
Coverage (enter
required code)
15 Employee Share
of Lowest Cost
Monthly Premium,
for Self-Only
Minimum Value
Coverage

16 Applicable
Section 4980H Safe
Harbor (enter code,
if applicable)

Part III

Covered Individuals
If Employer provided self-insured coverage, check the box and enter the information for each covered individual.
(a) Name of covered individual(s)

(b) SSN

(d) Covered
all 12 months

(e) Months of Coverage

Jan

Feb

Mar

Apr

May

June

July

Aug

Sept

Oct

Nov

Dec

1. Full-Time Employees are generally those individuals working in excess of 30
hours per week in a month on average.

Bryant serves as regulatory counsel to ILMA through Bassman,
Mitchell, Alfano & Leiter Chtd. He may be reached at 202-386-7670 or
dbryant@bmalaw.net.

22
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Vol. 66 No. 11 * 26 * November 2016 Compoundings

Cat. No. 60705M

Form 1095-C (2015)

http://www.irs.gov/form1094c http://www.irs.gov/form1095c

ILMA Compoundings November 2016

Table of Contents for the Digital Edition of ILMA Compoundings November 2016