2020
                                                       Form MA 1099-HC                                                                                                                                                       Massachusetts
                                                                                                                                                                                                                             Department of
                                                       Individual Mandate                                                                                                                                                    Revenue
                                             Massachusetts Health Care Coverage
1. Name of insurance company or administrator                                                                                                                               2. FID number of insurance co. or administrator

3. Name of subscriber                                                                                4. Date of birth                                                       5. Subscriber number

6. Street address                                                                                    7. City/Town                                                           8. State                                   9. Zip

Full-year minimum creditable coverage?   If No, check months with minimum creditable coverage:                                                                                                        Corrected:
   Yes No                                    Jan. Feb. Mar.                                             Apr. May June July Aug.                                                Sept. Oct.       Nov.                         Dec.
a. Name of dependent                            Date of birth                            Subscriber number

Full-year minimum creditable coverage?   If No, check months with minimum creditable coverage:                                                                                                        Corrected:
   Yes No                                    Jan. Feb. Mar.                                             Apr. May June July Aug.                                                Sept. Oct.       Nov.                         Dec.
b. Name of dependent                           Date of birth                            Subscriber number

Full-year minimum creditable coverage?   If No, check months with minimum creditable coverage:                                                                                                        Corrected:
   Yes No                                    Jan. Feb. Mar.                                             Apr. May June July Aug.                                                Sept. Oct.       Nov.                         Dec.
c. Name of dependent                            Date of birth                            Subscriber number

Full-year minimum creditable coverage?   If No, check months with minimum creditable coverage:                                                                                                        Corrected:
   Yes No                                    Jan. Feb. Mar.                                             Apr. May June July Aug.                                                Sept. Oct.       Nov.                         Dec.
d. Name of dependent                           Date of birth                            Subscriber number

Full-year minimum creditable coverage?   If No, check months with minimum creditable coverage:                                                                                                        Corrected:
   Yes No                                    Jan. Feb. Mar.                                             Apr. May June July Aug.                                                Sept. Oct.       Nov.                         Dec.