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2. Forms
4. 1095-B Form Request
6. Effective as of the 2024 reporting year, employers are no longer required to distribute a printed 1095-C to all full-time / benefits-eligible employees. Now, these forms only need to be provided upon request.

   Employees and former employees may request a copy of their 1095-B form. 

8. First Name*
10. Middle initial
12. Last Name*
14. Department where you worked in 2025*
16. Email Address where you want the form sent*
18. Phone Number (###-###-####)*
20. How Would you like the from sent to you? Select one*

    1. Email
    2. Mail

    If you select mail we will send it to the last address we have in our system.

22. Please review the information you entered above. Is everything correct? *

    1. Yes - everything is correct
Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field