Form 1095-B provides information regarding any coverage you may have been enrolled in during the 2015 calendar year with a given insurance carrier. It will also list your spouse and/or any dependents who may have been enrolled in that same health plan. You can use the information on this form as proof of coverage for yourself and your enrolled family members. This information is proof to the IRS that you do not owe a penalty tax due to being uninsured.

1. CBIZ EMPLOYEE SERVICES ORGANIZATION
©Copyright2016.CBIZ,Inc.NYSEListed:CBZ.Allrightsreserved.
Form 1095-B
Why Am I Receiving This?
The Affordable Care Act (ACA) requires insurance carriers to provide members enrolled in
their health plans a Form 1095-B by March 31. This requirement goes into effect in 2016.
Form 1095-B provides information regarding any coverage you may have been enrolled in during the 2015 calendar
year with a given insurance carrier. It will also list your spouse and/or any dependents who may have been enrolled
in that same health plan. You can use the information on this form as proof of coverage for yourself and your
enrolled family members. This information is proof to the IRS that you do not owe a penalty tax due to being
uninsured.
While the information obtained from the 1095-B Forms can be helpful in completing your tax return for 2015, it is
not required and should not be submitted with your return. If you have not received these forms by the time you file
your tax return, you may use other forms of documentation to determine if you had health coverage, including:
• Insurance cards
• Explanation of benefits
• Statement from your insurer
• W-2 or payroll statements reflecting health
insurance deductions
If you and your entire family were covered for the entire year, you may check the full-year coverage box (A) on your
return (as shown below).
If you or your family members did not have coverage for one or more months of the calendar year, you may claim an
exemption or make an individual shared responsibility payment by completing IRS Form 8965 and reporting the
amount in the space provided (B).
What does Form 1095-B look like?
For more information, please visit
https://www.irs.gov/Affordable-Care-Act/Questions-and-Answers-about-Health-Care-Information-Forms-for-Individuals
My Form 1095-B information is
incorrect. Who do I contact?
If your Form 1095-B information is incorrect,
please contact your HR department to make
the change. An example of wrong information
would be an incorrect Social Security Number.
For the 2015 Tax Year, individuals who file their tax return before they receive their 1095 Forms, will not be
required to amend their return, but should keep all pertinent tax information as part of their records.
If you have additional questions about
how your 1095 Forms relate to your tax
return, please consult a tax professional.