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2021 1094/1095 Printing & Filing Service Enrollment Form

EmailEnter the same email address which you signed in with:

Company Name

Applicable company codes:For multiple companies, enter all company codes separated by a comma. IE. 9999, 9999A, 9999B

First Name

Last Name

Title

Phone Number

Comments

I agree to the $4.00 fee per 1095 form and $100 filing fee per company code, plus shipping/delivery fees. Subject to a minimum fee of $750

Agree

UPLOAD FILE

Please note: 1095s will be delivered/shipped using the same delivery/shipping method as your W-2s.

FC

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