Employee 1095 Request

Email

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As a result of the Paperwork Burden Reduction Act and Employer Reporting Improvement Act, signed into law in January of 2025, employees are no longer required to have a 1095 form that confirms health insurance eligibility for the year 2024 and moving forward. Therefore, current employees will not longer receive the form because it is no longer required (or needed). If you would like a 1095 form, we will still send you one.

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Last (4) Digits of Social Security Number*

Store Number

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EMPLOYEE
1095 FORM REQUEST

YOU MUST BE 21 YEARS OR OLDER

EMPLOYEE 1095 FORM REQUEST

Employee 1095 Request

EMPLOYEE
1095 FORM REQUEST