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Get and Sign Form 1095 C Employer Provided Health Insurance Offer and Coverage 2021-2022
8 Employer identification number EIN 10 Contact telephone number 6 Country and ZIP or foreign postal code 11 City or town Employee Offer of Coverage Employee s Age on January 1 Feb Mar Apr May Plan Start Month enter 2-digit number June July Aug Sept Nov Oct Dec 14 Offer of Coverage enter required code Required Contribution see instructions 16 Section 4980H Safe Harbor and Other Relief enter code if applicable 17 ZIP Code For Privacy Act and Paperwork Reduction Act Notice see separate...Show details
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