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TF5095 2019 Laser ACA 1095B Health Coverage 8 1/2 X 11"

Manufacturer: NEBS
Manufacturer Part No: TF5095
TF5095 2019 Laser ACA 1095B Health Coverage
Size: 8 1/2 X 11"

This form is used by insurance carriers for reporting which months the insured and his or her family were covered under the plan.
Meet your reporting requirements under the Affordable Care Act (ACA) by using this form to report employees covered by your health plan.

  • 2-sided form
  • Black ink imprint
  • Laser form - for Pressure Seal please see product TF5506 here
  • For IRS copy in landscape format you must use product TF5096L here
  • Typically used by payroll companies and smaller employers with self-funded insurance plans who have fewer than 50 full-time employees (FTEs) that worked at least one month during the year..
  • Compatible with laser and inkjet printers.
  • This form is not available in multiple copies.  You must order for the total number of copies you need (ex. 50 employees - in most cases you will need one copy for the employee, one for the employer, and one for the IRS so you must order quantity 150).
  • Packaged in quantities of 100.
  • 100% Satisfaction Guarantee.
  • Higher quantities are available at discounted prices.
  • Speak to a customer service specialist at 855-5FORMS5 or 855-536-7675. 8AM - 7PM EST Monday - Thursday and 8AM - 5PM EST on Friday.



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$16.20 TF5095 2019 Laser ACA 1095B Health Coverage 8 1/2 X 11"

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