PART III EMPLOYER REVIEW
Reporting year / ALE member:
Plan and funding arrangement:
Employee enrollment reference:
Covered person internal ID | Relationship | Identifier source | Start | End | Reported months
Employee-spouse duplicate review:
Date-of-birth alternative and solicitation evidence, if applicable:
Retroactive enrollment changes:
Source person-month count:
Form person-month count:
Unresolved difference / owner:
Reviewer / approval date:
Released return reference: