3895: California Health Insurance Marketplace Statement (2024)
California · FTB · Used for tax years 2024
California Form 3895 is a Health Insurance Marketplace Statement for 2024. It reports policy details, covered individuals and coverage dates, along with monthly enrollment premiums, second lowest cost silver plan premiums, and advance payments of the premium assistance subsidy.
Questions people ask
What is Form 3895?
It is the California Health Insurance Marketplace Statement. This version is for tax year 2024.
What policy information does the form show?
The form has fields for the Marketplace identifier, Marketplace-assigned policy number, policy issuer’s name, and policy start and termination dates.
What information appears in Part I?
Part I, Covered Individuals, has spaces for each covered person’s name, Social Security number, date of birth, and coverage start and termination dates.
What amounts appear in Part II?
Part II, Coverage Information, has monthly entries for enrollment premiums, second lowest cost silver plan (SLCSP) premiums, and advance payments of the premium assistance subsidy. It covers January through December and includes annual totals.
Where can I find the privacy notice?
The form says to get FTB 1131 EN-SP for the privacy notice.