Form 1095-C: Employer-Provided Health Insurance Offer and Coverage
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For Applicable Large Employers (ALEs), HR teams, and payroll providers
ALE HR team, benefits administrator, or payroll provider generating annual ACA Form 1095-C statements? Batch-fill 25 to 500 employee Form 1095-C PDFs (Line 14 Offer codes 1A–1U, Line 15 cost, Line 16 Safe Harbor 2A–2I) from your HRIS/payroll Excel or CSV export.
JustFill generates completed Form 1095-C PDFs for employee distribution and record-keeping; it does not transmit ACA AIR XML filings to the IRS (employers filing 10 or more information returns must e-file through the IRS ACA Information Returns system).JustFill is not affiliated with IRS. This is an independent third-party tool to help you complete Form 1095-C. Always download the current blank form from the official source and verify your completed copy before signing or submitting. Official Form 1095-C from IRS
IRS Form 1095-C, Employer-Provided Health Insurance Offer and Coverage, is the mandatory Affordable Care Act (ACA) information return that Applicable Large Employers (ALEs with 50 or more full-time and full-time-equivalent employees) must prepare for every full-time employee each year. It reports the employer's health coverage offer (Part II Line 14 codes 1A–1U), the lowest-cost self-only Employee Required Contribution (Line 15), Section 4980H Safe Harbor codes (Line 16 codes 2A–2I), and covered individuals under self-insured plans (Part III). Open the official Form 1095-C PDF in JustFill to fill a single statement or batch-generate 25 to 500 employee 1095-C PDFs from an HRIS/payroll Excel or CSV export.
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Preparing annual ACA health coverage statements for your workforce or correcting an employee's Form 1095-C? Under Internal Revenue Code Section 6056, every Applicable Large Employer (ALE — generally businesses, nonprofits, and government entities averaging 50+ full-time and FTE employees in the prior calendar year) must furnish a separate Form 1095-C to each full-time employee and transmit copies to the IRS alongside Form 1094-C. Because every employee needs an individualized PDF showing their monthly Line 14 Offer of Coverage code, Line 15 lowest-cost monthly premium contribution, and Line 16 Section 4980H affordability safe harbor code, HR teams, payroll providers, and CPA firms use JustFill to import their HRIS/benefits Excel or CSV export, map the ALE Member employer block once, and batch-generate reviewable Form 1095-C PDFs for the entire workforce.
Applicable Large Employers (ALEs with 50+ full-time and full-time-equivalent employees) face strict annual IRS deadlines to furnish a completed Form 1095-C to every full-time employee. Manually typing Part I employee demographics and Part II monthly Line 14 Offer of Coverage codes (1A–1U), Line 15 Employee Required Contribution amounts, and Line 16 Section 4980H Safe Harbor codes (2A–2I) across dozens or hundreds of PDFs is slow and error-prone.
With JustFill, HR managers, benefits administrators, and CPA firms export their benefits matrix from Excel or CSV, lock the ALE Member employer block (Lines 7–13), and batch-generate individual Form 1095-C PDFs alongside their broader workforce and tax compliance forms.
Related IRS & B2B Compliance Forms
The official IRS Form 1095-C PDF (OMB No. 1545-2251, 4 pages) is a free fillable PDF at irs.gov/pub/irs-pdf/f1095c.pdf. Click "Fill the blank Form 1095-C now" above to load the official IRS blank in JustFill, or upload an HRIS/payroll Excel or CSV file to batch-generate employee Form 1095-C statements in one ZIP archive.
What each section of Form 1095-C asks for. JustFill’s AI will detect these fields automatically when you upload the PDF — review the breakdown below so you know what to enter.
Employee name, Social Security Number (SSN), and street address (Lines 1–6), plus the ALE Member employer name, Employer Identification Number (EIN), street address, and contact telephone number (Lines 7–13).
Two-digit Plan Start Month (01–12) and the monthly (or "All 12 Months") Series 1 indicator code describing the coverage offered to the employee: e.g., 1A (Qualifying Offer), 1E (Minimum Essential Coverage providing Minimum Value offered to employee, spouse, and dependents), or 1H (No offer of coverage).
The employee's monthly dollar share of the lowest-cost self-only minimum essential coverage providing minimum value (entered in dollars and cents, e.g., $118.50, when codes 1B, 1C, 1D, 1E, 1J, 1K, or 1L–1U are used on Line 14; left blank when 1A or 1H applies).
Monthly (or "All 12 Months") Series 2 code showing why the employer is not subject to an assessable payment under Section 4980H: e.g., 2A (employee not employed during the month), 2B (not a full-time employee), 2C (employee enrolled in coverage offered), 2D (limited non-assessment waiting period), 2F (Form W-2 affordability safe harbor), 2G (federal poverty line safe harbor), or 2H (rate of pay safe harbor).
The employee's primary residence or work-location ZIP code used to determine affordability, completed only by employers offering an Individual Coverage Health Reimbursement Arrangement (ICHRA, codes 1L–1U).
Completed only if the employer offers self-insured coverage in which the employee or family members enrolled: name, SSN (or date of birth if no SSN), and months covered (All 12 Months or Jan–Dec checkboxes) for each covered individual.
A fictional 75-employee Texas manufacturer, Sample Horizon Manufacturing Inc., offers a fully insured group health plan (calendar-year plan starting in January) to a full-time employee who enrolled for all 12 months.
SAMPLE, JORDAN K · SSN •••-••-•••• · 410 Example Meadow Ln, Austin, TX 78745
Identifies the full-time employee receiving the Form 1095-C statement.
Sample Horizon Manufacturing Inc. · EIN 74-•••••82 · 900 Industrial Sample Blvd, Austin, TX 78744 · (512) 555-01••
Matches the employer EIN and contact details reported on the transmittal Form 1094-C.
Plan Start Month: 01 · Line 14 (All 12 Months): 1E
Code 1E indicates Minimum Essential Coverage providing Minimum Value was offered to the employee, spouse, and dependents for all 12 months.
All 12 Months: $125.00
The employee's monthly contribution for the lowest-cost self-only minimum-value coverage.
All 12 Months: 2C · Part III left blank (fully insured plan)
Code 2C reports that the employee enrolled in the offered coverage for every day of all 12 months.
These values are made up. They are here to show what belongs on each line, not to be copied — every name, number, and address on your own Form 1095-C has to be your own.
Applicable Large Employers furnish a copy of Form 1095-C to each full-time employee and file the employer copies with the IRS alongside Form 1094-C. Employers filing 10 or more information returns in aggregate must file electronically via the IRS AIR system; smaller paper filers mail to the service center for their principal place of business.
Use this if the address is in: Alabama, Arizona, Arkansas, Connecticut, Delaware, Florida, Georgia, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Mississippi, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Texas, Vermont, Virginia, West Virginia
Use this if the address is in: Alaska, California, Colorado, District of Columbia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, North Dakota, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Utah, Washington, Wisconsin, Wyoming
Employees do not attach Form 1095-C to their personal Form 1040 tax return — they keep their copy with their tax records.
Checked against the official IRS instructions on 2026-10-21. Destinations change — confirm on the IRS page before you send anything.
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For Applicable Large Employers (ALEs), HR teams, and payroll providers
Import your employee roster from Excel or CSV, map Part I employee details and Part II monthly offer/cost/safe-harbor columns once while keeping your ALE Member employer block (Lines 7–13) fixed, and export one reviewable Form 1095-C PDF per employee.
Dedicated guide & CSV template: Batch fill employee Form 1095-C PDFs from Excel/CSV
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We load the official IRS blank for you — no download needed. Or upload your own copy below.
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PDF, Word (.docx), JPG, PNG, WebP, HEIC, GIF and BMP. Free account required, no credit card.
First hand-filled PDF (up to 15 pages) is free with no watermark. Need more or AI Auto-Fill? Grab the $7 7-Day Pass (25 clean PDF downloads + 25 AI credits, $7 credited toward $19/mo Starter).
By uploading, you confirm you have the legal right to use this document.
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Official source: Form 1095-C on IRS’s website
Edition checked: 2026 Form 1095-C (OMB No. 1545-2251; 4 pages). Verified against the official source on .
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