Part 3 of the form includes information about you and the individuals (including dependents) covered under your self-insured plan.


While Part 2 will tell the IRS if your employer offered coverage, Part 3 shows who accepted
the offer and is actually covered. 
The box will be checked for any month that you were
enrolled in coverage for at least one day. For example, if you enrolled in coverage on July 31,
the box will be checked for the month of July.