2024 Form 1095-C Employer Health Coverage

--- ## Page 1 ### Form 1095-C **Employer-Provided Health Insurance Offer and Coverage** - ☐ VOID - ☐ CORRECTED **OMB No. 1545-2251** **2024** b00120 **Department of the Treasury** **Internal Revenue Service** ▸ Do not attach to your tax return. Keep for your records. ▸ Go to www.irs.gov/Form1095C for instructions and the latest information. --- ### Part I Employee | | | |:---|:---| | **1 Name of employee** | **2 Social security number (SSN)** | | Johan Jongsma | ***-**-4568 | | **3 Street address (including apartment no.)** | | | 851 Brightwaters Blvd Ne | | | **4 City or town** | **5 State or province** | **6 Country and ZIP or foreign postal code** | | St Petersburg | FL | 33704 | ### Applicable Large Employer Member (Employer) | | | |:---|:---| | **7 Name of employer** | **8 Employer identification number (EIN)** | | Kaseya US Sales, LLC | 46-0522543 | | **9 Street address (including room or suite no.)** | **10 Contact telephone number** | | 701 Brickell Avenue Suite 400 | (415)-694-5700 | | **11 City or town** | **12 State or province** | **13 Country and ZIP or foreign postal code** | | Miami | FL | 33131 USA | --- ### Part II Employee Offer and Coverage **Employee's Age on January 1:** **Plan Start Month** (Enter 2-digit number): **01** | | All 12 Months | Jan | Feb | Mar | Apr | May | June | July | Aug | Sept | Oct | Nov | Dec | |:---|:---:|:---:|:---:|:---:|:---:|:---:|:---:|:---:|:---:|:---:|:---:|:---:|:---:| | **14** Offer of Coverage (enter required code) | | 1H | 1H | 1H | 1H | 1H | 1A | 1A | 1A | 1A | 1A | 1A | 1A | | **15** Employee Required Contribution (see instructions) | $ | $ | $ | $ | $ | $ | $ | $ | $ | $ | $ | $ | $ | | **16** Section 4980H Safe Harbor and Other Relief (enter code, if applicable) | | 2A | 2A | 2A | 2A | 2D | 2G | 2G | 2G | 2G | 2G | 2G | 2G | **17 ZIP Code** --- ### Part III Covered Individuals ☒ If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee. | (a) Name of covered individual(s) | (b) SSN or other TIN | (c) DOB (if SSN or other TIN is not available) | (d) Covered all 12 months | (e) Months of Coverage | |:---:|:---:|:---:|:---:|:---:| | | | | | Jan | | | | | | Feb | | | | | | Mar | | | | | | Apr | | | | | | May | | | | | | June | | | | | | July | | | | | | Aug | | | | | | Sept | | | | | | Oct | | | | | | Nov | | | | | | Dec | | | | | | | |:---:|:---:|:---:|:---:|:---:| | **18** | | | | | | **19** | | | | | | **20** | | | | | | **21** | | | | | | **22** | | | | | | **23** | | | | | | **24** | | | | | | **25** | | | | | | **26** | | | | | | **27** | | | | | | **28** | | | | | | **29** | | | | | | **30** | | | | | | **31** | | | | | | **32** | | | | | | **33** | | | | | | **34** | | | | | | **35** | | | | | --- For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. **Cat. No. 60705M** **Form 1095-C (2024)** --- ## Page 2 ### Form 1095-C (2024)                                                    Page 2 **Instructions for Recipient** You are receiving this Form 1095-C because your employer is an Applicable Large Employer subject to the employer shared responsibility provisions in the Affordable Care Act. This Form 1095-C includes information about the health insurance coverage offered to you by your employer. Form 1095-C, Part II, includes information about the coverage, if any, your employer offered to you and your spouse and dependent(s). If you purchased health insurance coverage through the Health Insurance Marketplace and wish to claim the premium tax credit, this information will assist you in determining whether you are eligible. If you or your family members are eligible for certain types of minimum essential coverage, you may not be eligible for the premium tax credit. For more information about the premium tax credit, see Pub. 974, Premium Tax Credit (PTC). You may receive multiple Forms 1095-C if you had multiple employers during the year that were Applicable Large Employers (for example, you left employment with one Applicable Large Employer and