Request a 1095-C Statement
If you want to receive a copy of your most recent tax year Form 1095-C, you may request it by completing the 1095-C Request Form and submitting it via email to [email protected]. Please allow 10 business days for processing plus delivery time.
Click here to request your 1095-C Form.
Have questions about the information on the 1095-C Tax Form? See our FAQ section below.
1. What is the Form 1095-C?
Form 1095-C is like a Form W-2. Employers send a copy to the Internal Revenue Service (IRS), and you can receive a copy upon request. Form W-2 reports your annual earnings. Form 1095-C reports your health care coverage throughout the year.
2. What am I supposed to do with this form?
Keep it for your tax records. You don’t need this form to file your taxes, but when you do file, you’ll have to tell the IRS whether or not you had health insurance for each month of the applicable tax year. The Form 1095-B from your insurance carrier shows if you had health insurance through your employer. Since you don’t need the Form 1095-C to file your taxes, you don’t have to wait to receive it if you already know what months you did or didn’t have health insurance in during the applicable tax year.
3. What information is provided on Form 1095-C?
Part I: Provides detailed information regarding the employer and employee.
Part II: Provides the following information:
+ Line 14: Shows when the employee was offered medical coverage for each month of the calendar year. Definitions for the codes shown on the form are listed on the back of the Form 1095-C.
+ Line 15: Shows the employee’s share of the lowest cost monthly employee-only premium that the County offers. This may not be the amount the employee actually paid if the employee chose a different health plan or covered dependents.
+ Line 16: Reflects any safe harbor relief, per IRS Code Section 4980H, that may apply. The code(s) listed provide the IRS with information to administer the employer shared responsibility provisions.
Part III: This section is blank. The County does not provide self-insured medical coverage and, therefore, is not required to complete this section.
4. How can I receive a copy of the Form 1095-C?
Your employer during 2024, County of Santa Clara, will provide a Form 1095-C upon request. Complete the Form 1095-C Request Form and submit it via email to [email protected] to receive a copy by mail or by email. You may also receive a 1095-B form from your health insurance company that contains similar information.
5. What if I get more than one 1095 form?
Someone who had health insurance through more than one employer during the year may receive a 1095-B or 1095-C from each employer/health insurance company. Some employees may receive a Form 1095-A and/or 1095-B reporting specific health coverage details. Just keep these – You do not need to send them in with your tax return.
6. What if I did not get a Form 1095-B or 1095-C?
Employers and health insurers are no longer required to issue a Form 1095-B or 1095-C to you.
If you would like to receive a copy, you must request it by submitting the Form 1095-C Request Form to your Department Employee Service Center.
7. I have more questions – Who do I contact?
Please contact the Employee Benefits Department by phone at (408) 970-2600 or by email at [email protected]. You can also go to the IRS website called https://www.irs.gov/affordable-care-act/questions-and-answers-about-health-care-information-forms-for-individuals that covers most of what you need to know.
The County of Santa Clara
Employee Benefits Department
400 Race Street | Suite 201
San Jose, CA 95126
(408) 970-2600
[email protected]