Part III - Issuer or Other Coverage Provider
Line 16: Name of the Issuer
In line 16, Enter the name of the person who is considered as the issuer or coverage provider.
Line 17: EIN of the Issuer
Enter the 9-digit employer identification number (EIN) of the issuer in line 17.
A SSN may not be used instead of an EIN. If you do not have an EIN, you can apply for one online at www.irs.gov, or by faxing or mailing Form SS-4 to the IRS.
Line 18: Contact number
In line 18: Enter the phone number of the person who is responsible for answering individuals regarding their coverage.
Line 19: Street address (including room or suite no.)
Line 20: City or town
Line 21: State or province
Line 22: Country and ZIP or foreign postal code
In Lines 19-22, enter the complete address of the issuer where all correspondence regarding the filing may be sent. A P.O. Box may be entered in lieu of a street address if that's how mail is received by the filer.