1095-C EMPLOYER FIELD REVIEW
Reporting year:
ALE member / internal employer ID:
Employee internal ID (no SSN in this checklist):
Population reason: full-time / enrolled self-insured / other reviewed rule
Part I source and exceptions:
Line 14 monthly source:
Line 15 contribution source and effective dates:
Line 16 rationale and exceptions:
Part III required? Funding arrangement:
Covered-person exceptions:
Draft version:
Reviewer and review date:
Outstanding decisions:
Approved filing batch / acknowledgment reference:
Employee furnishing reference: