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.
95DWENV05 - Moisture Seal
95DWENVS05 - Self Seal
1964 - Larger, for inserters
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 firstname.lastname@example.org.
Thank you for showing interest in this item. You will be notified by email as soon as this item is available to purchase.
The item you selected has already been subscribed to notify to this email.
System error: Failed to submit email, please contact website administrator.