1095-C Request Form

1095-C Request Form
Form 1095-C is a tax form that illustrates if you had health insurance through your employer. Since you do not actually need this form 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).

Starting in 2025 employers are no longer required to automatically distribute Form 1095-C to all employees and instead it will be provided upon request.

To request your 1095-C, please complete the fields below and click "submit."
Date*

MonthDayYear
Date
Your Name: *
Your Email:*
example@example.com
Your Department: *
For what year are you requesting the 1095-C? *
Any additional comments or questions?
Should be Empty: