DECLINED COVERAGE: EMPLOYER 1095-C REVIEW
Year / ALE member:
Employee internal ID:
ACA full-time months:
Offer document and effective dates:
Waiver received / effective date:
Line 14 determination by month:
Required contribution source:
Line 15 required for selected code?
Line 16 candidate and factual support:
Unresolved exception / owner:
Self-insured enrollment records checked:
Approved answer for employee inquiries:
Reviewer / date: