Transmittal of Health Coverage Information Returns

• Legal Form Number: 1094-B
• Year: 2025
• Issuer: Treasury Department
• Section: Treasury Department

110116

Form 1094-B

2023

Transmittal of Health Coverage Information Returns

Department of the Treasury

Internal Revenue Service Go to www.irs.gov/Form1094B for instructions and the latest information.

OMB No. 1545-2252

1 Filer’s name 2 Employer identification number (EIN)

3 Name of person to contact 4 Contact telephone number

5 Street address (including room or suite no.) 6 City or town

7 State or province 8 Country and ZIP or foreign postal code

9 Total number of Forms 1095-B submitted with this transmittal . . . . . . . . . . . . . . .

For Official Use Only

Under penalties of perjury, I declare that I have examined this return and accompanying documents, and to the best of my knowledge and belief, they are true, correct, and complete.

Signature Title Date

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 61570P Form 1094-B (2023)