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Page 2 of 4 Fileid: … ns/I8963/201801/A/XML/Cycle04/source 10:37 - 15-Feb-2018
The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.
The term “health insurance” Obtaining consents from all controlled overnight deliveries on the “Address
TIP includes limited scope (also called group members that are required to be (continued)” line.
stand-alone) dental and vision listed on Schedule A of this form, and
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
electronically, select the full name of the
For the definitions of controlled group, If the IRS selects the designated entity, country from the drop down in the foreign
single-person covered entity and then all members of the controlled group country name box. Enter foreign province
designated entity, see Specific that are required to be listed on or state, and postal code.
Instructions, next. Schedule A of this form will be deemed to
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 Single-Person Covered Entity
Covered entity information. A covered affiliated group. You must also sign Part I or Designated Entity (Agent of
entity is either a single-person covered on page 1 (see Part I signature
entity or a member of a controlled group. A instructions below). Also complete the first an Affiliated Group, or Other
single-person covered entity is a covered line of Schedule A, with your National Designated Entity) and Consent
entity that is not a member of a controlled Association of Insurance Commissioners by the Designated Entity (if
group. Under the controlled group rule of (NAIC) company and group code and net applicable)
ACA section 9010(c)(3), all persons premiums written, if any.
Provide the date signed in MM/DD/YYYY
treated as a single employer under Box 2b. Other. Check box 2b if you are format, your phone and fax numbers, and
sections 52(a), 52(b), 414(m), or 414(o) the designated entity for a covered entity the name and title of your signing official in
will be treated as one covered entity. In that is not an affiliated group. You must print format.
applying the single employer rules, ACA also sign Part I on page 1 (see Part I
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
treated as being a member of a controlled not manually sign the form. Instead,
group if it is a member of the group at the Corrected report. Check the box if this is manually sign, scan, and upload Form
end of the day on December 31, 2017, a corrected report. 8453-R with your Form 8963. See How To
and would qualify as a covered entity in Employer identification number (EIN). File, earlier.
2018 if it were a single-person covered Enter your EIN. If you do not have an EIN, Part II. Alternate Contact
entity. you must apply for one. If filing your Form
Box 1. Single-person covered entity. 8963 electronically, enter your 9-digit EIN Person Designee
Check box 1 if you are a single-person without the dash. The EIN will be properly If you want to designate an employee to
covered entity. You must sign Part I on formatted for you. discuss the report with the IRS, check the
related box and enter the person’s name,
page 1 (see Part l signature instructions Number of controlled group members title, phone number, and fax number, and
below). Also complete the first line of included in Schedule A. Enter the we will contact that person if we have any
Schedule A. number of controlled group members who questions concerning the report.
Designated entity. Each controlled are listed on Schedule A, including the
group must have a designated entity. entity in box 2a or 2b. If reporting as a Schedule A. Single-Person
single-person covered entity, enter “1” for Covered Entity or Controlled
If the controlled group, without regard the number of controlled group members.
to foreign corporations included under Group Member Information
ACA section 9010(c)(3)(B), is also an Entity name. If you checked box 1, enter Enter the single-person covered entity,
affiliated group that files a consolidated the name of the single-person covered common parent of affiliated group, or
return for federal income tax purposes, the entity in the entity name box. If you designated entity information on the first
designated entity is the agent of the checked box 2a or 2b, enter the name of line. This information will automatically
affiliated group as identified on the tax the designated entity. If you have a trade populate the first line of Schedule A if you
return filed for the data year. name or are doing business under a complete the form electronically. It is
different name, enter that name or d/b/a
If not, the controlled group must select unnecessary to repeat the entity name
name on the “Entity name (continued)”
one of its members to be the designated and address from page 1 on line 1, but
line.
entity. you must enter all of the premium data
If a controlled group does not select a Address. Enter a street address where requested for the entity. Complete
designated entity, the IRS will select a you can receive overnight deliveries. additional lines for every person who is a
controlled group member at the end of the
member of the controlled group as the Do not provide a P.O. box. day on December 31, 2017, and who
designated entity for the controlled group.
The designated entity is responsible for CAUTION! would qualify as a covered entity in 2018 if
it were a single-person covered entity, and
the following for the group: enter the following information for each
Filing Form 8963, Third party. If you receive your mail in
Receiving IRS communications about care of a third party (such as an member.
the fee, accountant or an attorney), enter on the (a) Employer identification number
Filing any necessary error correction first street address line “C/O” followed by (EIN). If filing your Form 8963
report, the third party's name and enter the street electronically, enter your 9-digit EIN
Paying the fee to the IRS, address where the third party can receive without the dash. The EIN will be properly
formatted for you.
-2- Instructions for Form 8963 (Rev. 01-2018)
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