Blank Form 1095-B
Full page with preprinted instructions on back.
Use this blank laser form for printing form 1095-B. Folding perforation at 5 ½”. Order by number of sheets needed.
Note: Please check your software for 1095 Envelope compatibility
A 1095-B form must be issued by a self-insured employer with less than 50 full-time employees (including full-time equivalent employees), or by the insurer to employees and to the IRS as proof of healthcare coverage.
To order a free sample, please contact us at 1-800-968-1099, or email@example.com.