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ACA Forms Health Coverage for Self Insured Employers With Less Than 50 Employees - Paper Filing
Affordable Care Act (ACA) Health Coverage Forms for Self Insured Employers With Less than 50 Employees-  Filing on Paper.


ACA Forms Less Than 50 Employees - Paper filing
1094-B Transmittal of Health Coverage (Landscape) B1094B05 
1095-B a Health Coverage - (Landscape) B1095B05 
1095-B Continuation Form (Landscape) B1095BCON05 
1095-B Full Page Recipient Form (Portrait) B95BFPREC05 

Available in increments of 25
Total Percent Off Per Unit
$11.25 0% $0.4500
$15.75 30% $0.3150
$27.00 40% $0.2700
$49.50 45% $0.2475
$90.00 50% $0.2250
$95.65 57.5% $0.1913
$118.13 65% $0.1575
$132.80 70.5% $0.1328
$178.80 73.5% $0.1192
$281.25 75% $0.1125
$506.50 77.5% $0.1013
$945.00 79% $0.0945

Use these forms to file the Affordable Care Act Health Coverage for Self Insured Employers with less than 50 employees if you are reporting with paper forms.

Who is a self insured employer?   Self-insured employers, also known as “self-funded”, control what is covered through a customized plan.  The employer has liability for all claims and pays for each claim.

ACA reporting is mandatory for the calendar year 2015 and is the responsibility of the employer.

1094-B Transmittal Form (landscape style) to be used with Form 1095-B and mailed to the IRS.

1095-B Full Page Recipient Form (portrait style) to be mailed to recipients. See info on landscape style recipient form in next paragraph.  Instructions are on the back of the form.

1095-B Health Coverage Form (landscape style) mail to IRS with 1094-B Transmittal.  You may opt to send a copy of this form to the recipients instead of the portrait style form.  The Health Coverage Form is not formatted so that it will fit in a double window envelope.  You may also wish to order a copy of this form to file for your records. You may need to order 3 sets of this form (for IRS, for recipient, for your file).

1095-B Continuation Page (landscape style) Used if an individual employee needs more than 6 covered individuals listed on their form.

Three 1094-B transmittal forms are included with any order of 1095-B forms --  order additional transmittal forms if three is not enough.


Priced by the sheet. We are currently shipping 2023 forms. Image may reflect prior years.
Use envelope 95DWENV05/95DWENVS05 for portrait style recipient form.

Please review these other products:
1095 Double Window Envelope

Use this envelope for the portrait style recipient forms of the Affordable Care Act. 

The landscape style forms do not have a companion envelope.

The security tint and cellophane windows ensure privacy of your information.  This envelope is constructed of 24# envelope stock.


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