Issuer or Other Coverage provider Information

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, 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.