Employer Annual Reporting Form Instructions


Reporting Deadline

All Employers covered by the Health Care Security Ordinance or the Fair Chance Ordinance are required to submit the 2015 Employer Annual Reporting Form. Please note that the reporting deadline has been extended from Saturday, April 30th to Monday, May 2nd, 2016.

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


Before You Begin

You are not required to submit the 2015 Employer Annual Reporting Form 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 2015; or 
  • You had no employees within the geographic boundaries of San Francisco (including employees working from home in San Francisco) in any quarter of 2015.

You do not need to notify the City that you are not required to submit the Form; no further action is requiredIf you received a mailing saying that you might be required to submit the Employer Annual Reporting Form, you do not need to request removal from the mailing list. The list was based on information you provided in your last tax filing. By providing current, correct information on your 2015 tax filing, you will be removed from next years' list.

If you were covered for one or more quarters of 2015, 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 a PDF Preview of the 2015 Employer Annual Reporting Form so you can review and print out the questions before you start the form. 

To complete the Employer Annual Reporting Form, you will need information on:

  • Your seven-digit Business Account Number;
  • The total number of persons employed (including those outside of San Francisco) 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 for each quarter of 2015, including:
    • Total payments for health insurance (medical, dental, vision as well as Taft-Hartley plan contributions);
    • Total contributions to the City Option (Healthy San Francisco and MRAs);
    • Total allocations to revocable expenditures (such as revocable Health Reimbursement Accounts) and amounts paid out from revocable benefits (such as reimbursements to employees)
    • Total contributions to Health Savings Accounts or other irrevocable reimbursement accounts. 
  • Surcharges collected from customers to cover, in whole or in part, the cost of complying with the HCSO
  • Compliance with the Fair Chance Ordinance, including how arrest and conviction history information was used in hiring.


Tips for Completing the Annual Reporting Form

  • Do not submit two separate 2015 Annual Reporting Forms using the same Business Account Number unless you are submitting a correction. If multiple businesses or locations share the same Business Account 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.
  • 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. 
  • You may report multiple types of health care expenditures for each employee. For example, if you paid health insurance premiums and also paid into a HRA for a particular employee, the employee would be counted in responses on both the Health Insurance page and the Revocable Expenditure page.
  • Employees who worked for you throughout the year should be counted in each quarter.
  • If you cannot access the online form, please call (415) 554-7892 to request a paper copy of the Annual Reporting Form.
  • The Annual Reporting Form is designed to be viewed with © MS Internet Explorer 9.0.

Business Account 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 Account 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 visit the website for the  Office of the Treasurer & Tax Collector to register your business before completing the Employer Annual Reporting Form. 

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Name and Address

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

For the address, please fill in the business address you would like us to use if we have questions regarding your Annual Reporting Form.


Business Type

Check the "nonprofit" check box if you are submitting the form on behalf of an IRS-recognized nonprofit organization.

Check the "control group" check box if you are submitting the form on behalf of more than one entity in the same controlled group of corporations. A "controlled group of corporations" is as a combination of two or more corporations that are under common control as defined in Section 1563(a) of the United States Internal Revenue Code.


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 during that quarter.

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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 also earned at least $90,745.00 (or $43.63 hourly) in 2015.
  • Persons who were eligible to receive Medicare coverage;
  • Persons who were eligible for TRICARE (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 and also received 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.

For “Amount employer 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 2015 plan year (minus administrative fees) or the average actual expenditure amounts. For information, see our Administrative Guidance on this topic.

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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 2015, 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 2015. 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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Revocable Health Care Expenditures (such as revocable Health Reimbursement Accounts)

A Revocable Health Care Expenditure is a Health Care Expenditure that the employer has “allocated for use by a Covered Employee but not actually paid to the employee, or any amount actually paid to a third party administrator that could revert to the employer at any point.”  None of the money actually has to revert to the employer for the Health Care Expenditure to be revocable.  Rather, the entire expenditure is considered revocable if there is the possibility that any or all of it could be returned to the employer.

Employer contributions to a revocable Health Reimbursement Account (also referred to as a Health Reimbursement Arrangement or HRA) are the most common type of Revocable Health Care Expenditures.  An expenditure made to an HRA is considered revocable if the employer allocates the funds as a debit on its books, but does not actually pay the allocated funds into a separate account on the employee’s behalf within 30 days of the end of each quarter.  An HRA is also considered revocable if any amount of the employer’s Health Care Expenditure could be returned to the employer at any point, such as when the employee leaves the job or an employer contribution “expires.”is an employer-funded account or program that reimburses employees for qualified medical expenses up to a maximum dollar amount for a coverage period.

To qualify as a Health Care Expenditure under the HCSO, employers must make funds available for a minimum of 24 months from the date of the contribution, provide notifications to employees about the accounts, and meet other criteria. In addition, only 40% of Health Care Expenditures for each employee could be revocable in 2015. Please review OLSE's Administrative Guidance on revocable health care expenditures


For “dollar amount allocated to the benefit,” indicate the amount of money allocated to the revocable health care benefit for Covered Employees for the quarter. For example, for a revocable HRA, this would be the maximum amount made available for reimbursement for hours payable during the quarter.

For “dollar amount actually paid out (such as reimbursements from an HRA),” indicate the amount of money that was actually paid to the employee or service provider for Health Care Services  during each quarter of 2015. This includes reimbursements to the employee from the HRA or other spending from revocable benefit.

Check the appropriate box to indicate whether the HRA program was self-administered, meaning the employer administered the program, or whether it was Third-Party Administered, meaning employees sought reimbursements through an independent party.

Check the appropriate boxes to indicate the types of health care services covered by the revocable benefit, such as the costs for which your employees could receive reimbursements under the terms of your HRA.

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Irrevocable Reimbursement Accounts, such as HSAs

Irrevocable Reimbursement Accounts are reimbursement programs in which the funds never revert to the employer under any circumstance. See the HCSO Administrative Guidance on Irrevocable Expenditures for more informaiton. 

The most common type of Irrevocable Reimbursement Account is a Health Savings Account (HSA). 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 Irrevocable Reimbursement Account 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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Fair Chance Ordinance Reporting


1) Include part-time, temporary, seasonal employees, as well as telecommuters who work within the geographic boundaries of San Francisco.

2) Report on whether your company or organization's employment application for jobs in San Francisco ask about arrest or conviction information.  This can include an online application template that is not specific to San Francisco, but that is used by applicants for San Francisco jobs.

3) Report on whether the company or organization conducted background checks on conviction and or arrest records before a live interview (including a telephone interview)?

4) For more information on the types of information that employers may never ask about see Fair Chance Ordinance FAQ #26 (PDF).

5) Report on whether you changed your job application process during calendar year 2015 to comply with the San Francisco Fair Chance Ordinance:

  • Yes, we changed our application and/or background check process. We changed how/whether/when we inquire about conviction and arrest histories.
  • No, our existing application and/or background check process was already compliant with the law. We do inquire about conviction and arrest histories, but how we do already complied with the requirements of the Fair Chance Ordinance.
  • No, we never considered arrest records or convictions, and we still do not.
  • No, we have not yet changed our process to comply with the law.

6) Please report on the number of people you hired with a conviction history during 2015.

7) Indicate if your business is not covered by the background check provisions of the FCO. This may be the case if:

a) you covered by federal or state law that requires you to conduct background checks (such as in financial services industries, schools, etc); or

b) you are exempted from background check provisions of the FCO because your employees work with minors, seniors, or disabled individuals, or your employees are drivers.  

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.