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Employer Annual Reporting Form Instructions


Reporting Deadline

All employers covered by the Health Care Security Ordinance (HCSO) are required to submit the 2014 Annual Reporting Form by April 30, 2015.

Covered Employers who fail to submit the Annual Reporting Form will be subject to a penalty of $500 per quarter.


Before You Begin

You were not covered by the HCSO if:

  • You are a private employer and you employed fewer than 20 persons (including those employed outside of San Francisco) in each of the four calendar quarters of 2014; or
  • You are a non-profit corporation and you employed fewer than 50 persons (including those employed outside of the City) in each of the four calendar quarters of 2014; or
  • You had no covered employees in San Francisco during 2014.

Employers who were not covered by the HCSO in any of the quarters of 2014 should not complete the 2014 Annual Reporting Form. You do not need to notify the City that you were not covered; no further action is required. If you were covered for one or more quarters, you are required to complete the form.

Please read these instructions before you begin. Note that once you have begun the Annual Reporting Form online, you will not be able to save it and return to it later.

You may want to download screen shots of the Annual Reporting Form (PDF) so you can review and print out the questions before you start the Form. 

To complete the Form, you will need information on:

  • Your Business Account Number;
  • The total number of persons employed (worldwide) for each quarter within specific ranges (i.e. 0-19, 20-49, etc.);
  • The number of employees covered by the HCSO for each quarter;
  • Total health care expenditures made in each quarter of 2014, including:
    • Total payments for health insurance (medical, dental, and vision);
    • Total contributions to the City Option (Healthy San Francisco and MRAs);
    • Total contributions to Health Savings Accounts and Medical Savings Accounts;
    • Total allocations to and total reimbursements from Health Reimbursement Accounts; and
  • Surcharges collected from customers to cover, in whole or in part, the cost of complying with the HCSO.


Tips for Completing the Annual Reporting Form

  • The Annual Reporting Form is designed to be viewed with © MS Internet Explorer 9.0.
  • Do not submit two separate 2014 Annual Reporting Forms using the same Business Account Number unless you are submitting a correction. If multiple businesses or locations share the same Business Registration Certificate Number, please combine the relevant data into a single Annual Reporting Form. If multiple forms are submitted, only the most recent submission will be recorded.
  • You may report multiple types of health care expenditures for each employee. For example, if you paid health insurance premiums and paid into a reimbursement account for a particular employee, the employee would be counted in responses on pages 3 and 4. Employees who worked for you throughout the year should be counted in each quarter.
  • Fill out the form completely. Do not enter commas in numeric fields. Please enter zeroes where appropriate. Enter all dollar amounts in whole dollars; do not include cents. 
  • If you cannot access the online form, please call (415) 554-7892 to request a paper copy of the Annual Reporting Form.

Business Registration Certificate Number

Please enter your seven-digit San Francisco Business Account Number and click "Validate.”

This number can be found on the Business Registration Certificate(s) issued by the San Francisco Treasurer & Tax Collector. You can also find your Business Registration Certificate Number by searching the San Francisco Data website.

Please note:

  • If your Business Registration Certificate Number is only six digits, please add a zero to the beginning of the number.
  • If you do not have a Business Registration Certificate, please contact the Office of the Treasurer & Tax Collector at (415) 554-4400 and register your business before completing the Annual Reporting Form.

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Name and Address

For the Business Name, please fill in the trade name (dba), if different than the registered name of the business.

Business Type

Please select the appropriate check box if you are submitting this form on behalf of a nonprofit organization or on behalf of several entities in the same “control group.”

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Business Size

Include all persons who performed work for your business regardless of whether they worked inside or outside of San Francisco. Indicate the size in of the business in each quarter.

In reporting business size, include all employees, regardless of their status or classification as seasonal, permanent or temporary, managers, full-time or part-time, contracted (whether employed directly by the employer or through a temporary staffing agency, leasing company, professional employer organization, or other entity) or commissioned.

If the number of persons who performed work for your business fluctuated during a quarter, answer this question based on the average number of persons who performed work each week.

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Covered Employees

Count the total number of persons who were “Covered Employees” under the HCSO during the quarter. Covered Employees are those who:

  • Qualified as employees entitled to payment of the San Francisco minimum wage (pursuant to the Minimum Wage Ordinance, Chapter 12R of the San Francisco Administrative Code);
  • Were employed by your business for 90 calendar days after his or her first day of work (including any period of leave to which an employee is legally entitled); and
  • Regularly performed at least 8 hours of work per week for your business within the geographic boundaries of San Francisco. For an employee without a regular schedule, you may average his or her hours over the 13 weeks in the quarter.

Covered Employees may include employees for whom you complied with the HCSO by providing health insurance, paying into the City Option, contributing to a reimbursement account, or making other health care expenditure.

Do not include your employees who met any of the following exemption criteria:

  • Persons who were managerial, supervisory, or confidential employees and earned at least $88,212.00 (or $43.63 hourly) in 2014.
  • Persons who were eligible to receive Medicare coverage;
  • Persons who were eligible for TRICARE/CHAMPUS (the federal health care program for active duty and retired members of the uniformed services, their families, and survivors);
  • Persons who were “covered employees” under the San Francisco Health Care Accountability Ordinance (HCAO), which applies only to City Contractors (see Section 12Q of the San Francisco Administrative Code for more details about HCAO coverage);
  • Persons who were employed by a nonprofit corporation for up to one year as trainees in a bona fide training program consistent with federal law; or
  • Persons who voluntarily signed a revocable HCSO waiver form, which indicated they were receiving health care benefits through another employer (either as an employee or by virtue of being the spouse, domestic partner, or child of another person). The form is effective for one year from the date it is signed, and is available at the HCSO website.

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Health Insurance

For “Number of Persons,” include any employees covered by the HCSO:

  • For whom you paid a health insurance carrier to provide group coverage, including medical, vision and/or dental;
  • For whom you made contributions to a Taft-Hartley plan pursuant to a collective bargaining agreement or union contract; or
  • Who were covered under your self-insured plan. A “self-insured” or “self-funded, group health plan” is one in which the employer assumes the financial risk for providing health care benefits to its employees.

For “Dollar Amount Spent,” do not count 1) insurance premium contributions made by employees, or 2) expenditures for life insurance, workers’ compensation, or disability insurance.

Tip: Employers with self-insured plans may calculate these expenditures using either the COBRA equivalent rate for the 2014 plan year (minus any administrative fees) or the average actual expenditure amounts.

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City Option (Healthy San Francisco and MRAs)

If you contributed to the City Option (Healthy San Francisco or the City’s Medical Reimbursement Accounts) for one or more of your covered employees in 2014, report the number of covered employees for whom you made contributions and the total dollar amount contributed for each quarter.

To find this information, refer to the “Employee Rosters” you submitted to the City Option for the four calendar quarters of 2014. You can access this information by logging into your account via the employer login page at http://sfcityoption.org/employers/employer-portal.

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Health Reimbursement Accounts (HRAs)

A Health Reimbursement Arrangement (HRA) is an employer-funded account or program that reimburses employees tax free for qualified medical expenses up to a maximum dollar amount for a coverage period. Note that to qualify as a health care expenditure that satisfies the Employer Spending Requirement of the HCSO, employers must make funds available for a minimum of 24 months from the date of the contribution, and they must provide notifications to employees about the accounts. Please review the FAQs on reimbursement programs.

For “Dollar Amount Allocated,” indicate the amount of money that was made available to the Covered Employees for whom you had a reimbursement plan. This is the maximum amount made available for reimbursement.

For “Dollar Amount Reimbursed,” indicate the amount of money that was actually reimbursed to the Covered Employees during 2014 or paid directly to a health care provider for services rendered.

Check the appropriate box to indicate whether the reimbursement program was Self-administered, meaning the employer administered the program, or whether it was 3rd Party Administered, meaning employees sought reimbursements through an independent party.

If your plan restricted the types of eligible medical expenses for which your employees could receive reimbursements, report which types of expenses are not reimbursable.

Report the number of Covered Employees for whom you only provided access to an HRA, meaning that you did not also pay for medical insurance or another type of health care expenditure.

Stand-Alone HRAs

Integrated HRAs

Addendum on EBHRAs

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Health Savings Accounts (HSAs)

Health Savings Accounts (HSAs) are tax-exempt accounts that are distinct from HRAs (described above).  An employee must be covered under a high deductible health plan to have an HSA . Funds contributed to these accounts are owned by the employee. See IRS Publication 969 for more information.

If you contributed to an HSA for any of your covered employees, report the total employer contribution to those accounts. Do not count any money contributed by employees.

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If you added a surcharge to your customers’ bills that you described as specifically intended for employees’ health care benefits (such as a “Healthy San Francisco surcharge” “or an “employee health care surcharge” on a restaurant check), select “Yes,” and report the full amount collected through the surcharge.

If you added a surcharge to your customers’ bills that covered health care costs in addition to other costs, such as a charge for “San Francisco Employer Mandates,” select “Yes,” and report only the portion of surcharge that was collected for health care costs.

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 Corrections / Resubmissions

Corrections / Resubmissions

If you made a mistake on your Annual Reporting Form, you may re-submit a corrected form. Start a new form at https://etaxstatement.sfgov.org/OLSE

The corrected submission will replace any form submitted previously with the same Business Registration Certificate Number.

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 This notice is intended to provide general information and does not establish policy or offer legal advice regarding the HCSO, Chapter 14 of the San Francisco Administrative Code. If you have any questions about your obligations under the ordinance, please visit www.sfgov.org/olse/hcso, call (415) 554-7892 or email hcso@sfgov.org.




Last updated: 1/27/2015 4:16:28 PM