CBIZ ACA CheckPoint Request Form

Under 20 Employees Client Level-Funded or Self-Funded ACA Reporting Request for 2023 Reporting Year

By enrolling in CBIZ ACA CheckPoint E-File Complete Employer ACA reporting for the 2023 Tax Year, I certify, on behalf of our organization that the organization is not considered an Applicable Large Employer (ALE) for 2023 Tax Year, employing less than 50 employees in 2022. I further certify our organization is the sponsor of a level-funded or self-funded health plan for 2023 for employees, spouses, partners and/or dependents, and is required to report to employees and to the IRS on Form 1094/1095-B for 2023.

In order to complete the 1094/1095-B forms for 2023, your CBIZ team member must receive a list of the individuals covered in 2023, along with their SSNs and mailing address for the employee (primary covered individual) from the employer, their benefits consultant or carrier. CBIZ will reach out to your company contact with a request for information, if this information has not already been provided prior to completion of 1095-B forms. CBIZ may rely on the information provided by you and shall have no responsibility to inquire into its correctness or accuracy.

The following services will be provided in order to meet your obligation to report to covered individuals (employees) of the coverage they were enrolled in for any part of any month in 2023, in the form of the 1095-B. This form will be completed and mailed to employees by the March 1, 2024 (March 2, 2024 falls on a Saturday, but 2024 is a leap year, so March 1, 2024 is the due date), postmark date.

In addition, CBIZ will prepare and e-file forms 1094-B and 1095-B to the IRS via electronic filing by the due date to the IRS of April 1, 2024 (March 31, 2024, falls on a Sunday) and will provide the employer shown below with proof of filing upon Accepted or Accepted with Errors outcome and Receipt Id issuance from the IRS. In addition, if applicable, forms for covered individuals who reside in California, New Jersey, Washington DC, or Rhode Island will be filed electronically to the states in the format required prior to the deadline for filing forms in those states.

CBIZ’s liability shall be limited only to substantiated and proven direct damages for any claims arising hereunder and shall not be liable for losses incurred by you for indirect, punitive, special or consequential damages arising out of any breach of this agreement.

I acknowledge the fee for CBIZ ACA CheckPoint E-File Complete of $159.00 will be due and payable prior to production of 1094/1095-Bs. In addition, the cost of print to mail fulfillment of $3.50 per 1095-B to be sent to employees by March 1, 2024, will also be due and all is payable prior to forms being sent out to covered individuals, including a 3% processing fee for credit card payment. I understand that I will be contacted by email and phone regarding credit card charges when forms are ready for processing.

I further acknowledge that forms will be sent out and e-filing will take place only after payment is confirmed.

By entering your name bel.ow, you acknowledge that you are authorized to certify, acknowledge and agree to the terms stated above

Authorized Contact Person for Organization

Authorized Person for Organization*

First NameLast Name

Title*

Title of Authorized Person

E-mail Address*

Phone Number*

Area CodePhone Number

Client/Account Information

Legal Business name*

Employer Identification Number*

Street address*

Street address line 2

City*

State*

Zip code*

Actual Number of Employees Based on W2s issued in 2022*

Calendar Year Plan?

If no, what month does plan renew?

Additional Information