If there are multiple companies involved, please combine total headcount.

Contact Information
Estimate W-2s Issued:

Enter the number of w-2's issued to:

Enter the number of w-2's issued to:

Enter the number of w-2's issued to:

Medical Insurance Information
General Information:

1095EZ Online provides the service of 1095-C/1094-C form preparation based on data provided by its clients. It does not provide advice on company policies, insurance selections, safe harbors and/or alternative furnishing methods for each client (unless separately contracted for consulting services). It can, however, educate about the meaning of alternatives, the data required for each alternative, and the implications of each selection; after evaluating, client can direct 1095EZ Online how to complete the returns.