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The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.
reinsurance ceded from direct premiums below). Also complete the first line of Number of controlled group members
written. However, filers may not include Schedule A. included in Schedule A. Enter the
indemnity reinsurance written in direct number of controlled group members who
Designated entity. Each controlled
premiums written and may not deduct are listed on Schedule A, including the
group must have a designated entity.
indemnity reinsurance ceded from direct entity in box 2a or 2b. If reporting as a
premiums written. If the controlled group, without regard
single-person covered entity, enter “1” for
to foreign corporations included under
the number of controlled group members.
U.S. health risk. A U.S. health risk ACA section 9010(c)(3)(B), is also an
means the health risk of any individual affiliated group that files a consolidated Entity name. If you checked box 1, enter
who is: return for federal income tax purposes, the the name of the single-person covered
• A U.S. citizen, designated entity is the agent of the entity in the entity name box. If you
• A resident of the United States (within affiliated group as identified on the tax checked box 2a or 2b, enter the name of
the meaning of section 7701(b)(1)(A)), or return filed for the data year. the designated entity. If you have a trade
• Located in the United States, with If not, the controlled group must select name or are doing business under a
respect to the period that individual is so one of its members to be the designated different name, enter that name or d/b/a
located. entity. name on the “Entity name (continued)”
line.
Health insurance. In general, the term If a controlled group does not select a
“health insurance” has the same meaning designated entity, the IRS will select a Address. Enter a street address where
as the term “health insurance coverage” in member of the controlled group as the you can receive overnight deliveries.
section 9832(b)(1)(A), defined to mean designated entity for the controlled group. Do not provide a P.O. box.
benefits consisting of medical care The designated entity is responsible for
(provided directly, through insurance or the following for the group: CAUTION!
reimbursement, or otherwise) under any • Filing Form 8963,
hospital or medical service policy or • Receiving IRS communications about Third party. If you receive your mail in
certificate, hospital or medical service plan the fee, care of a third party (such as an
contract, or health maintenance • Filing any necessary error correction accountant or an attorney), enter on the
organization contract offered by a covered report, first street address line “C/O” followed by
entity. • Paying the fee to the IRS, the third party's name and enter the street
The term “health insurance” • Obtaining consents from all controlled address where the third party can receive
TIP includes limited scope (also called group members that are required to be overnight deliveries on the “Address
stand-alone) dental and vision listed on Schedule A of this form, and (continued)” line.
benefits under section 9832(c)(2)(A) and • Providing (to the IRS upon request) the Foreign address. If reporting a
retiree-only health insurance, but does not consents obtained from controlled group foreign address, include the full name of
include any other excepted benefits under members that are required to be listed on the country using uppercase letters in
section 9832(c). Schedule A of this form. English. If you file Form 8963
If the IRS selects the designated entity, electronically, select the full name of the
For the definitions of controlled group, then all members of the controlled group country from the drop down in the foreign
single-person covered entity, and that are required to be listed on country name box. Enter foreign province
designated entity, see Specific Schedule A of this form will be deemed to or state, and postal code.
Instructions, next. have consented to this election.
Part I. Signature of Official
Box 2a. Agent of an affiliated group.
Signing on Behalf of the
Specific Instructions Check box 2a if you are the agent of an
affiliated group. You must also sign Part I Single-Person Covered Entity
Covered entity information. A covered on page 1 (see Part I signature or Designated Entity (Agent of
entity is either a single-person covered instructions below). Also complete the first an Affiliated Group, or Other
entity or a member of a controlled group. A line of Schedule A, with your National
single-person covered entity is a covered Association of Insurance Commissioners Designated Entity) and Consent
entity that is not a member of a controlled (NAIC) company and group code and net by the Designated Entity (if
group. Under the controlled group rule of premiums written, if any. applicable)
ACA section 9010(c)(3), all persons
treated as a single employer under Box 2b. Other. Check box 2b if you are Provide the date signed in MM/DD/YYYY
sections 52(a), 52(b), 414(m), or 414(o) the designated entity for a covered entity format, your phone and fax numbers, and
will be treated as one covered entity. In that is not an affiliated group. You must the name and title of your signing official in
applying the single employer rules, ACA also sign Part I on page 1 (see Part I print format.
section 9010(c)(3)(B) provides that a signature instructions below). Also If you file Form 8963 by paper,
foreign entity subject to tax under section complete the first line of Schedule A, with manually sign the form.
881 is included within a controlled group your NAIC company and group code and
under section 52(a) or 52(b). A person is net premiums written, if any. If you file Form 8963 electronically, do
not manually sign the form. Instead,
treated as being a member of a controlled Corrected report. Check the box if this is manually sign, scan, and upload Form
group if it is a member of the group at the a corrected report. 8453-R with your Form 8963. See How To
end of the day on December 31, 2019,
and would qualify as a covered entity in Employer identification number (EIN). File, earlier.
2020 if it were a single-person covered Enter your EIN. If you do not have an EIN,
entity. you must apply for one. If filing your Form Part II. Alternate Contact
8963 electronically, enter your 9-digit EIN Person Designee
Box 1. Single-person covered entity. without the dash. The EIN will be properly If you want to designate an employee to
Check box 1 if you are a single-person formatted for you. discuss the report with the IRS, check the
covered entity. You must sign Part I on
page 1 (see Part l signature instructions related box and enter the person’s name,
title, phone number, and fax number, and
-2- Instructions for Form 8963 (Rev. 01-2020)
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