3895: California Health Insurance Marketplace Statement (2025)
California · FTB · Used for tax years 2025
California Form 3895 is the California Health Insurance Marketplace Statement for 2025. It reports covered individuals, coverage dates, monthly enrollment premiums, second lowest cost silver plan premiums, and advance payments of premium assistance subsidies.
Questions people ask
What policy information appears on the 2025 Form 3895?
The form has fields for the Marketplace identifier, Marketplace-assigned policy number, policy issuer’s name, and policy start and termination dates.
What information is listed for covered individuals?
Part I has spaces for each covered individual’s name, Social Security number, date of birth, and coverage start and termination dates.
What coverage amounts does the form show?
Part II has monthly entries for enrollment premiums, the second lowest cost silver plan (SLCSP) premium, and advance payments of the premium assistance subsidy. It also includes annual totals.
Where can I find the privacy notice?
The form says to get FTB 1131 EN-SP for the privacy notice.