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  • Void Corrected Health Coverage Transmittal

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    Uma Karmakar
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    This document contains a summary of health insurance coverage for multiple individuals. It includes names, addresses, social security numbers, dates of birth, months of health insurance coverage, and employer information for over a dozen people. Personal information is redacted with "###".

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    Original Title

    1095-b Import Sample

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    This document contains a summary of health insurance coverage for multiple individuals. It includes names, addresses, social security numbers, dates of birth, months of health insurance coverage, and employer information for over a dozen people. Personal information is redacted with "###".

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
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    18 views11 pages

    Void Corrected Health Coverage Transmittal

    Uploaded by

    Uma Karmakar
    This document contains a summary of health insurance coverage for multiple individuals. It includes names, addresses, social security numbers, dates of birth, months of health insurance coverage, and employer information for over a dozen people. Personal information is redacted with "###".

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 11

    Void Corrected 1 First Name (Policy Holder) Middle Name Last Name Suffix

    0 0 Erich James Ruth Jr.

    0 0 Paul Thomas Blount

    0 0 Megan Elizabeth Johnson


    0 0 Robert Bradford Hoffstein II
    2 SSN 3 DOB 4 Address Line 1 4 Address Line 2 5 City 6 State 7 Country Code
    398-12-3456 9/3/1967 7 N Pinckney Street Suite 240 Madison WI

    791-35-6212 4/3/1965 5712 Ringtail Drive Apt 101 DeForest WI

    345-74-7431 ### 491 East Pioneer Road Unit 402 Beloit WI


    612-24-6178 ### 511 Monona Dr Middleton WI
    7 ZIP 8 Origin of Policy 9 Blank 10 Employer Name Line 1 10 Employer Name Line 2 11 EIN
    53703 A National Software DBA 1099 FIRE 12-3456789

    53511 B 1099Fire 23-4567890

    53532 A National Law Forms 35-7637367


    53707 A Med Claim Software 47-1246111
    12 Address Line 1 12 Address Line 2 13 City 14 State 15 Country Code
    12 South Park Place Suite 101 Phoenix AZ

    51 Main Street DeForest WI

    59 Washington Ave Beloit WI


    98 Lincoln Street Suite 512 Middleton WI
    15 Zip 16 Issuer Name Line 1 16 Issuer Name Line 2 17 EIN 18 Phone number 19 Address Line 1
    85208 Humana 23-4567890 800-350-8262 19 Williams Dr

    53533 Aetna 23-4567890 800-311-2000 20 Dover Drive

    53534 Cigna 53-1342123 877-444-1234 41 Bristol Lane


    53707 Blue Cross 78-1615822 800-100-1000 59 Craig Ave
    19 Address Line 2 20 City 21 State 22 Country Code22 ZIP First Name (Covered Individuals)
    Suite 964 Kansas City KS 64101 Erich
    Rebecca
    Ellen
    Nicholas
    Jenny
    Kansas City KS 64101 Paul
    Adam
    Betty
    Chloe
    Doris
    Edwin
    Frank
    Gabriel
    Suite 85 Chicago IL 60123 Megan
    Detroit MI 41212 Tilly
    Zoe
    Middle Name Last Name Suffix SSN
    James Ruth Jr 398-12-3456
    Ann Ruth 563-53-1235
    Josephine Ruth 111-11-1111
    Michael Ruth 222-22-2222
    Mae Ruth 333-33-3333
    Thomas Blount 791-35-6212
    Joseph Blount 444-56-7890
    Michelle Blount 555-61-1341
    Dianne Blount 663-12-3345
    Kirstin Blount 777-34-1324
    Thomas Blount 888-13-1272
    Benton Blount 999-72-2784
    Daniel Blount 101-17-9345
    Elizabeth Johnson 345-74-7431
    M Hoffstein 203-16-7124
    P Hoffstein 331-17-8221
    Covered
    DOB (if SSN is not all 12
    available) months January February March April May June July
    9/3/1967 YES 1 1 1 1 1 1 1
    3/3/1969 YES 1 1 1 1 1 1 1
    3/3/2006 YES 1 1 1 1 1 1 1
    10/7/2009 YES 1 1 1 1 1 1 1
    7/15/2015 NO 0 0 0 0 0 0 1
    4/3/1965 YES 1 1 1 1 1 1 1
    2/5/2001 YES 1 1 1 1 1 1 1
    4/5/2003 YES 1 1 1 1 1 1 1
    3/7/2005 YES 1 1 1 1 1 1 1
    4/6/2008 YES 1 1 1 1 1 1 1
    3/7/2011 YES 1 1 1 1 1 1 1
    5/23/2013 YES 1 1 1 1 1 1 1
    8/19/2015 NO 0 0 0 0 0 0 0
    10/12/1980 YES 1 1 1 1 1 1 1
    7/1/1999 YES 1 1 1 1 1 1 1
    10/4/2004 YES 1 1 1 1 1 1 1
    Novembe Decembe
    August September October r r
    1 1 1 1 1
    1 1 1 1 1
    1 1 1 1 1
    1 1 1 1 1
    1 1 1 1 1
    1 1 1 1 1
    1 1 1 1 1
    1 1 1 1 1
    1 1 1 1 1
    1 1 1 1 1
    1 1 1 1 1
    1 1 1 1 1
    1 1 1 1 1
    1 1 1 1 1
    1 1 1 1 1
    1 1 1 1 1
    1094-B Transmittal of Health Coverage Information Returns

    1 - Filer's name

    3 - Contact (First Name) Middle Last Suffix

    5 - Street Address (including room or suite no) 6 - City or town

    7 - State or province 8 - Country and ZIP or foreign postal code

    9 - Total Number of Forms 1095-B submitted with this transmittal

    Signature Title
    2 - Employer EIN

    4 - Contact telephone number

    ZIP or foreign postal code

    Date

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