Former Employees – Form 1095-C Availability Notice

Former Employees – Form 1095-C Availability Notice

Important Tax Information

If you were employed with Brockton Neighborhood Health Center during the 2025 calendar year, your Form 1095-C (Employer-Provided Health Insurance Offer and Coverage) is available upon request.

Form 1095-C contains important information about the health coverage offered to you and may be needed for your tax records.

Request a Copy of Your Form 1095-C

To receive a copy of your Form 1095-C please contact Michelle Rocheleau. You can use the form (below) to contact me directly. Or, mail a letter to me at:

103 Commercial St.
4th Floor
Brockton, MA 02302

When requesting your form, please provide:

Your full name (as it appeared during employment)
Last four digits of your Social Security Number. Important: do not include your complete SSN.
Current mailing address
Approximate dates of employment

Requests will be processed promptly.

Thank you,

Michelle Rocheleau
Payroll & Benefits Manager

Request Your Form 1095-C

For former BNHC employees only.

Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Your current mailing address (required)

Address your (approx.)

Last 4 digits of your SSN *

Last four digits of your Social Security Number. Do NOT include your complete SSN.

Start Date (approx.) *

Your approximate start date of employment at BNHC (required)

End Date (approx.) *

Your approximate end date of employment at BNHC (required)

Comment or Message

Photo by Polina Tankilevitch