How to Create Form 1095-B

Create Form 1095-B

1. Click on the Payer List button.
2. Double click on the payer name.
3. Highlight the recipient to add the form to.
4. Click on the Add Form button.
5. Select 1095-B from the Form Type drop down menu.
6. Fill in the necessary fields on the form.
7. Click Save.

Required Information

Corrected: Check if this box applies.

Issuer or Other Coverage Provider: Enter the Issuer or Other Coverage Provider's information on the Manage Payer screen (name, address, EIN, and contact information).

The following contact fields (entered on the Manage Payer screen) are required for filing 1095-B:

• 1095 Contact Phone/Ext: the phone number of a person that the 1095 Recipient/Responsible Individual may call for additional information.
• 1094 Contact Name and 1094 Contact Phone/Ext: name and phone number of a person that the IRS can contact for questions on a company's filing of ACA forms.

Responsible Individual: Line 8 - Enter letter identifying Origin of the Health Coverage (see IRS instructions for codes):

• A - Small Business Health Options Program (SHOP).
• B - Employer-sponsored coverage.
• C - Government-sponsored coverage.
• D - Individual market insurance.
• E - Multi-employer plan.
• F - Other designated minimum essential coverage.

Information about Certain Employer Sponsored Coverage: If the "Check if you are an insurer reporting employer sponsored coverage" checkbox is selected in Part II, the Sponsoring Employer Name, EIN, Address, City, State, and Zip Code fields will become available.

• Employer Name: Enter the Sponsoring Employer's Name.
• Employer Name 2: Enter the Sponsoring Employer's Name 2 (optional).
• EIN: Enter the Sponsoring Employer's EIN.
• Address: Enter the Sponsoring Employer's Address.
• Address 2: Enter the Sponsoring Employer's Address 2 (optional).
• Foreign Address: If the Foreign Address box is checked, you must select a Country Code from the drop down.
• City: Enter the Sponsoring Employer's City.
• State: Enter the Sponsoring Employer's State. If the If the Foreign Address box is checked, this field becomes State (Province).
• Zip Code and Extension: Enter the Sponsoring Employer's Zip Code and Extension. If the Foreign Address box is checked, this field becomes Postal Code.

Covered Individuals: Enter Covered Individuals using the “Cov Ind” button on the right side of the prep screen.

• At least one covered individual is required on Form 1095-B.
• If the form's Recipient (Employee) is enrolled in coverage, include the Recipient as a Covered Individual.
• Do not include covered individuals who waived coverage on the 1095-B.
• Name is filled from the respective fields on the Covered Individuals Window.
• SSN or other TIN is filled from the SSN or other TIN field on the Covered Individuals Window.
• Date of Birth is formatted as MM/DD/YYYY.
• The Months of Coverage (All 12 Months, or Jan, Feb, Mar, Apr, May, Jun, Jul, Aug, Sep, Oct, Nov, and Dec) will show an X or blank, as entered on the Covered Individuals Window.