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Affordable Care Act (ACA) Recipient Form (Portrait Style) Self-Insured Employer <50 Employees
Use this pre-printed laser form for printing form 1095-B.
B95BFPREC05
Pricing
Available in increments of 25
Quantity
 Total Percent Off Per Unit
$14.05 0% $0.5620
$19.67 30% $0.3934
$33.72 40% $0.3372
$61.82 45% $0.3091
$112.40 50% $0.2810
$119.45 57.5% $0.2389
$147.53 65% $0.1967
$165.80 70.5% $0.1658
$223.35 73.5% $0.1489
$351.25 75% $0.1405
$632.50 77.5% $0.1265
$1,180.00 79% $0.1180
Use this pre-printed laser form for printing form 1095-B. Folding perforation at 5 ½.  Full page form with instructions printed on the back.  A 1095-B form must be issued by a self-insured employer with less than 50 full-time employees (including full-time equivalent employees), or by the insurer to employees. 
Order one sheet per employee. 

Priced by the sheet. We are currently shipping 2025 forms
Use envelope 95DWENV05/95DWENVS05 with the portrait style recipient form.