Form 1095-B, Health Coverage Instructions
This form contains 355 fields organized into 21 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Coverage Details | ||
| topmostSubform[0].Page1[0].Table1_Part4[0].Row25[0].f1_37[0 | Text |
Provide additional information or notes related to the individual's coverage, if applicable.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row28[0].f1_51[0 | Text |
Enter a single character code indicating the type of coverage or other relevant information as specified in the form instructions.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row28[0].f1_52[0 | Text |
Provide additional information related to the coverage or individual as specified in the form instructions.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row29[0].f3_09[0 | Text |
Enter the policy number or other identifier for the coverage.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row29[0].f3_10[0 | Date |
Enter the start date of the coverage for the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row29[0].c3_01[0]_1 | CheckBox |
Check this box if the individual had coverage for at least one day in every month of the year.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row31[0].f3_20[0 | Text |
Enter the policy number associated with the covered individual's health coverage.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row32[0].f3_25[0 | Text |
Enter the policy number associated with the covered individual's health coverage.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row33[0].f3_30[0 | Text |
Enter the policy number associated with the covered individual's health coverage.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row34[0].f3_35[0 | Text |
Enter the policy number associated with the covered individual's health coverage.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row37[0].f3_50[0 | Text |
Enter the policy number associated with the health coverage.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row38[0].f3_54[0 | Text |
Enter the policy number associated with the covered individual's health coverage. Maximum length is 11 characters.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row38[0].f3_55[0 | Date |
Enter the start date of the coverage for the covered individual in MM/DD/YYYY format. Maximum length is 10 characters.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row40[0].f3_65[0 | Text |
Enter the policy number associated with the covered individual's health coverage.
|
| Coverage Information | ||
| topmostSubform[0].Page1[0].Pg1Header[0].cb_1[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the entire year.
|
| topmostSubform[0].Page1[0].Pg1Header[0].cb_1[1]_2 | CheckBox |
Check this box if the individual did not have minimum essential health coverage for the entire year.
|
| topmostSubform[0].Page1[0].Part1Contents[0].f1_10[0 | Text |
Enter the coverage year for which this form is being filled out.
|
| Coverage Months | ||
| topmostSubform[0].Page1[0].Table1_Part4[0].Row23[0].c1_01[0]_1 | CheckBox |
Check this box if the covered individual had minimum essential coverage for the month of January.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row23[0].c1_02[0]_1 | CheckBox |
Check this box if the covered individual had minimum essential coverage for the month of February.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row23[0].c1_03[0]_1 | CheckBox |
Check this box if the covered individual had minimum essential coverage for the month of March.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row23[0].c1_04[0]_1 | CheckBox |
Check this box if the covered individual had minimum essential coverage for the month of April.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row23[0].c1_05[0]_1 | CheckBox |
Check this box if the covered individual had minimum essential coverage for the month of May.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row26[0].c1_40[0]_1 | CheckBox |
Check this box if the covered individual had minimum essential coverage for January.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row26[0].c1_41[0]_1 | CheckBox |
Check this box if the covered individual had minimum essential coverage for February.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row26[0].c1_42[0]_1 | CheckBox |
Check this box if the covered individual had minimum essential coverage for March.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row26[0].c1_43[0]_1 | CheckBox |
Check this box if the covered individual had minimum essential coverage for April.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row26[0].c1_44[0]_1 | CheckBox |
Check this box if the covered individual had minimum essential coverage for May.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row27[0].c1_53[0]_1 | CheckBox |
Check this box if the covered individual had minimum essential coverage for January.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row27[0].c1_54[0]_1 | CheckBox |
Check this box if the covered individual had minimum essential coverage for February.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row27[0].c1_55[0]_1 | CheckBox |
Check this box if the covered individual had minimum essential coverage for March.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row27[0].c1_56[0]_1 | CheckBox |
Check this box if the covered individual had minimum essential coverage for April.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row27[0].c1_57[0]_1 | CheckBox |
Check this box if the covered individual had minimum essential coverage for May.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row34[0].c3_67[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row34[0].c3_68[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row34[0].c3_69[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row34[0].c3_70[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row34[0].c3_71[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for May.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row34[0].c3_72[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for June.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row34[0].c3_73[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for July.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row34[0].c3_74[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for August.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row34[0].c3_75[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for September.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row36[0].c3_93[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row36[0].c3_94[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row36[0].c3_95[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row36[0].c3_96[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row36[0].c3_97[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for May.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row36[0].c3_98[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for June.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row36[0].c3_99[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for July.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row36[0].c3_100[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for August.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row36[0].c3_101[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for September.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row37[0].c3_106[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row37[0].c3_107[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row37[0].c3_108[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row37[0].c3_109[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row37[0].c3_110[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for May.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row37[0].c3_111[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for June.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row37[0].c3_112[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for July.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row37[0].c3_113[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for August.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row37[0].c3_114[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for September.
|
| Coverage Period | ||
| topmostSubform[0].Page1[0].Table1_Part4[0].Row28[0].c1_66[0]_1 | CheckBox |
Check this box if the individual had coverage for the entire year.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row28[0].c1_67[0]_1 | CheckBox |
Check this box if the individual had coverage for the first quarter of the year.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row28[0].c1_68[0]_1 | CheckBox |
Check this box if the individual had coverage for the second quarter of the year.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row28[0].c1_69[0]_1 | CheckBox |
Check this box if the individual had coverage for the third quarter of the year.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row28[0].c1_70[0]_1 | CheckBox |
Check this box if the individual had coverage for the fourth quarter of the year.
|
| Coverage Provider | ||
| topmostSubform[0].Page1[0].Part1Contents[0].Line1[0].f1_02[0 | Text |
Enter the name of the employer or coverage provider.
|
| topmostSubform[0].Page3[0].Name_ReadOrder[0].f3_03[0 | Text |
Enter the name of the employer or coverage provider.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row29[0].f3_08[0 | Text |
Enter the name of the issuer or coverage provider.
|
| Coverage Type | ||
| topmostSubform[0].Page1[0].Table1_Part4[0].Row25[0].f1_36[0 | Text |
Enter the single character code that represents the type of coverage for the individual.
|
| Covered Individual | ||
| topmostSubform[0].Page1[0].Part1Contents[0].Line1[0].f1_03[0 | Text |
Enter the name of the covered individual.
|
| Covered Individual Conditions | ||
| topmostSubform[0].Page1[0].Table1_Part4[0].Row24[0].c1_14[0]_1 | CheckBox |
Check this box if the specific condition or requirement related to the covered individual is met.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row24[0].c1_15[0]_1 | CheckBox |
Check this box if the specific condition or requirement related to the covered individual is met.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row24[0].c1_16[0]_1 | CheckBox |
Check this box if the specific condition or requirement related to the covered individual is met.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row24[0].c1_17[0]_1 | CheckBox |
Check this box if the specific condition or requirement related to the covered individual is met.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row24[0].c1_18[0]_1 | CheckBox |
Check this box if the specific condition or requirement related to the covered individual is met.
|
| Covered Individual Details | ||
| topmostSubform[0].Page1[0].Table1_Part4[0].Row23[0].f1_26[0 | Text |
Enter a single character code that represents a specific status or condition related to the covered individual.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row23[0].f1_27[0 | Text |
Provide additional information or a code related to the covered individual. The exact nature of this information is unspecified.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row23[0].f1_28[0 | Text |
Enter the Social Security Number (SSN) or Tax Identification Number (TIN) of the covered individual. This field can contain up to 11 characters.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row23[0].f1_29[0 | Date |
Enter the date of birth of the covered individual in the format MM/DD/YYYY. This field can contain up to 10 characters.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row24[0].f1_31[0 | Text |
Enter a single character code representing a specific detail related to the covered individual. This field has a maximum length of 1 character.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row24[0].f1_32[0 | Text |
Provide additional information or a code related to the covered individual. The exact nature of the information required is not specified by the field name.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row24[0].f1_33[0 | Text |
Enter a numeric identifier or code related to the covered individual, with a maximum length of 11 characters.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row24[0].f1_34[0 | Text |
Enter a date or numeric value related to the covered individual, with a maximum length of 10 characters.
|
| Covered Individual Information | ||
| topmostSubform[0].Page1[0].Table1_Part4[0].Row26[0].f1_41[0 | Text |
Enter the first character of the covered individual's name. This is likely used for identification purposes.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row26[0].f1_42[0 | Text |
Enter the full name of the covered individual. This should match the name on their health coverage documents.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row26[0].f1_43[0 | Text |
Enter the Social Security Number (SSN) or Tax Identification Number (TIN) of the covered individual. This should be exactly 11 characters long.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row26[0].f1_44[0 | Date |
Enter the date of birth of the covered individual in the format MM/DD/YYYY. This should be exactly 10 characters long.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row27[0].f1_45[0 | Text |
Enter the name of the covered individual.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row28[0].f1_50[0 | Text |
Enter the name of the covered individual.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row28[0].f1_53[0 | Text |
Enter the Social Security Number (SSN) or Tax Identification Number (TIN) of the covered individual. This field can contain up to 11 characters.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row28[0].f1_54[0 | Date |
Enter the date of birth of the covered individual in the format MM/DD/YYYY. This field can contain up to 10 characters.
|
| Covered Individuals | ||
| topmostSubform[0].Page1[0].Table1_Part4[0].Row23[0].c1_06[0]_1 | CheckBox |
Check this box if the individual had minimum essential coverage for January.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row23[0].c1_07[0]_1 | CheckBox |
Check this box if the individual had minimum essential coverage for February.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row23[0].c1_08[0]_1 | CheckBox |
Check this box if the individual had minimum essential coverage for March.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row23[0].c1_09[0]_1 | CheckBox |
Check this box if the individual had minimum essential coverage for April.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row23[0].c1_10[0]_1 | CheckBox |
Check this box if the individual had minimum essential coverage for May.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row23[0].c1_11[0]_1 | CheckBox |
Check this box if the individual had minimum essential coverage for June.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row23[0].c1_12[0]_1 | CheckBox |
Check this box if the individual had minimum essential coverage for July.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row23[0].c1_13[0]_1 | CheckBox |
Check this box if the individual had minimum essential coverage for August.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row24[0].f1_30[0 | Text |
Enter the name of the individual covered by the health insurance.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row24[0].c1_19[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for January.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row24[0].c1_20[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for February.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row24[0].c1_21[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for March.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row24[0].c1_22[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for April.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row24[0].c1_23[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for May.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row24[0].c1_24[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for June.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row24[0].c1_25[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for July.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row24[0].c1_26[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for August.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row25[0].f1_35[0 | Text |
Enter the name of the individual covered by the health insurance.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row25[0].c1_32[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for January.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row25[0].c1_33[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for February.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row25[0].c1_34[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for March.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row25[0].c1_35[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for April.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row25[0].c1_36[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for May.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row25[0].c1_37[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for June.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row25[0].c1_38[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for July.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row25[0].c1_39[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for August.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row26[0].f1_40[0 | Text |
Enter the name of the covered individual.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row27[0].f1_46[0 | Text |
Enter the first character of the covered individual's name. This is likely used for identification purposes.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row27[0].f1_47[0 | Text |
Enter the full name of the covered individual. This should match the name on their health coverage documents.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row27[0].f1_48[0 | Text |
Enter the Social Security Number (SSN) or Tax Identification Number (TIN) of the covered individual. This should be up to 11 characters long.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row27[0].f1_49[0 | Date |
Enter the date of birth of the covered individual in the format MM/DD/YYYY. This should be up to 10 characters long.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row28[0].c1_71[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for January.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row28[0].c1_72[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for February.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row28[0].c1_73[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for March.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row28[0].c1_74[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for April.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row28[0].c1_75[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for May.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row28[0].c1_76[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for June.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row28[0].c1_77[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for July.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row28[0].c1_78[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for August.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row29[0].f3_06[0 | Text |
Enter the name of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row29[0].f3_07[0 | Text |
Enter the coverage month code for the covered individual. Use a single character code.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row29[0].c3_11[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of November.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row29[0].c3_12[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of December.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row29[0].c3_13[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row30[0].f3_11[0 | Text |
Enter the name of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row30[0].f3_12[0 | Text |
Enter the middle initial of the covered individual. This field accepts only one character.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row30[0].f3_13[0 | Text |
Enter the last name of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row30[0].f3_14[0 | Text |
Enter the Social Security Number (SSN) of the covered individual. This field accepts up to 11 characters.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row30[0].f3_15[0 | Date |
Enter the date of birth of the covered individual in the format MM/DD/YYYY. This field accepts up to 10 characters.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row30[0].c3_14[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row30[0].c3_15[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row30[0].c3_16[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row30[0].c3_17[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row30[0].c3_18[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row30[0].c3_19[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of May.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row30[0].c3_20[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of June.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row30[0].c3_21[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of July.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row30[0].c3_22[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of August.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row30[0].c3_23[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of September.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row30[0].c3_24[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row30[0].c3_25[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row30[0].c3_26[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row31[0].f3_16[0 | Text |
Enter the name of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row31[0].f3_17[0 | Text |
Enter the relationship code of the covered individual to the responsible individual. This is a single character code.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row31[0].f3_18[0 | Text |
Enter the Social Security Number (SSN) or Taxpayer Identification Number (TIN) of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row31[0].f3_19[0 | Date |
Enter the date of birth of the covered individual in the format MM/DD/YYYY.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row31[0].c3_27[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row31[0].c3_28[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row31[0].c3_29[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row31[0].c3_30[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row31[0].c3_31[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row31[0].c3_32[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for May.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row31[0].c3_33[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for June.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row31[0].c3_34[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for July.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row31[0].c3_35[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for August.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row31[0].c3_36[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for September.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row31[0].c3_37[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row31[0].c3_38[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row31[0].c3_39[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row32[0].f3_21[0 | Text |
Enter the name of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row32[0].f3_22[0 | Text |
Enter the relationship code of the covered individual to the responsible individual. This is a single character code.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row32[0].f3_23[0 | Text |
Enter the Social Security Number (SSN) or Tax Identification Number (TIN) of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row32[0].f3_24[0 | Date |
Enter the date of birth of the covered individual in the format MM/DD/YYYY.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row32[0].c3_40[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row32[0].c3_50[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row32[0].c3_51[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row32[0].c3_52[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row33[0].f3_26[0 | Text |
Enter the name of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row33[0].f3_27[0 | Text |
Enter the relationship code of the covered individual to the responsible individual. This is a single character code.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row33[0].f3_28[0 | Text |
Enter the Social Security Number (SSN) or Taxpayer Identification Number (TIN) of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row33[0].f3_29[0 | Date |
Enter the date of birth of the covered individual in the format MM/DD/YYYY.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row33[0].c3_53[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row33[0].c3_63[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row33[0].c3_64[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row33[0].c3_65[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row34[0].f3_31[0 | Text |
Enter the name of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row34[0].f3_32[0 | Text |
Enter the relationship code of the covered individual to the responsible individual. This is a single character code.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row34[0].f3_33[0 | Text |
Enter the Social Security Number (SSN) or Taxpayer Identification Number (TIN) of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row34[0].f3_34[0 | Date |
Enter the date of birth of the covered individual in the format MM/DD/YYYY.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row34[0].c3_66[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row34[0].c3_76[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row34[0].c3_77[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row34[0].c3_78[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row35[0].f3_36[0 | Text |
Enter the name of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row35[0].f3_37[0 | Text |
Enter the relationship code of the covered individual to the responsible individual. This is a single character code.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row35[0].f3_38[0 | Text |
Enter the Social Security Number (SSN) of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row35[0].f3_39[0 | Date |
Enter the date of birth of the covered individual in the format MM/DD/YYYY.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row35[0].c3_79[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row35[0].c3_89[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row35[0].c3_90[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row35[0].c3_91[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row36[0].f3_41[0 | Text |
Enter the name of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row36[0].f3_42[0 | Text |
Enter the relationship code of the covered individual to the responsible individual. This is a single character code.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row36[0].f3_43[0 | Text |
Enter the Social Security Number (SSN) or Taxpayer Identification Number (TIN) of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row36[0].f3_44[0 | Date |
Enter the date of birth of the covered individual in the format MM/DD/YYYY if SSN or TIN is not available.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row36[0].f3_45[0 | Date |
Enter the start date of coverage for the covered individual in the format MM/DD/YYYY.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row36[0].c3_92[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row36[0].c3_102[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row36[0].c3_103[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row36[0].c3_104[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row37[0].f3_46[0 | Text |
Enter the name of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row37[0].f3_47[0 | Text |
Enter the relationship code of the covered individual to the responsible individual. This is a single character code.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row37[0].f3_48[0 | Text |
Enter the Social Security Number (SSN) or Taxpayer Identification Number (TIN) of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row37[0].f3_49[0 | Date |
Enter the date of birth of the covered individual in the format MM/DD/YYYY.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row37[0].c3_105[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row37[0].c3_115[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row37[0].c3_116[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row37[0].c3_117[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row38[0].f3_51[0 | Text |
Enter the name of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row38[0].f3_52[0 | Text |
Enter the relationship code of the covered individual to the responsible individual. This is a single character code.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row38[0].f3_53[0 | Text |
Enter the Social Security Number (SSN) of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row38[0].c3_118[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row38[0].c3_128[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row38[0].c3_129[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row38[0].c3_130[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row39[0].f3_56[0 | Text |
Enter the name of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row39[0].f3_57[0 | Text |
Enter the relationship code of the covered individual to the responsible individual. This is a single character code.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row39[0].f3_58[0 | Text |
Enter the Social Security Number (SSN) or Taxpayer Identification Number (TIN) of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row39[0].f3_59[0 | Date |
Enter the date of birth of the covered individual in the format MM/DD/YYYY if SSN or TIN is not available.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row39[0].f3_60[0 | Date |
Enter the start date of coverage for the covered individual in the format MM/DD/YYYY.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row39[0].c3_131[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row39[0].c3_132[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row39[0].c3_133[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row39[0].c3_134[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row39[0].c3_135[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row39[0].c3_136[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for May.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row39[0].c3_137[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for June.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row39[0].c3_138[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for July.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row39[0].c3_139[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for August.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row39[0].c3_140[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for September.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row39[0].c3_141[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row39[0].c3_142[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row39[0].c3_143[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row40[0].f3_61[0 | Text |
Enter the name of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row40[0].f3_62[0 | Text |
Enter the relationship code of the covered individual to the responsible individual. This is a single character code.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row40[0].f3_63[0 | Text |
Enter the Social Security Number (SSN) or Taxpayer Identification Number (TIN) of the covered individual.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row40[0].f3_64[0 | Date |
Enter the date of birth of the covered individual in the format MM/DD/YYYY.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row40[0].c3_144[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for the month of April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row40[0].c3_154[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of January. Check the box if covered.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row40[0].c3_155[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of February. Check the box if covered.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row40[0].c3_156[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for the month of March. Check the box if covered.
|
| Covered Individuals - Monthly Coverage | ||
| topmostSubform[0].Page3[0].Table2_Part4[0].Row33[0].c3_54[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row33[0].c3_55[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row33[0].c3_56[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row33[0].c3_57[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row33[0].c3_58[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for May.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row33[0].c3_59[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for June.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row33[0].c3_60[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for July.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row33[0].c3_61[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for August.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row33[0].c3_62[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for September.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row35[0].c3_80[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row35[0].c3_81[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row35[0].c3_82[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row35[0].c3_83[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row35[0].c3_84[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for May.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row35[0].c3_85[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for June.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row35[0].c3_86[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for July.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row35[0].c3_87[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for August.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row35[0].c3_88[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for September.
|
| Covered Months | ||
| topmostSubform[0].Page1[0].Table1_Part4[0].Row26[0].c1_45[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for January.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row26[0].c1_46[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for February.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row26[0].c1_47[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for March.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row26[0].c1_48[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for April.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row26[0].c1_49[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for May.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row26[0].c1_50[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for June.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row26[0].c1_51[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for July.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row26[0].c1_52[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for August.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row27[0].c1_58[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for January.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row27[0].c1_59[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for February.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row27[0].c1_60[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for March.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row27[0].c1_61[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for April.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row27[0].c1_62[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for May.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row27[0].c1_63[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for June.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row27[0].c1_64[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for July.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row27[0].c1_65[0]_1 | CheckBox |
Check this box if the individual had minimum essential health coverage for August.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row29[0].c3_02[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row29[0].c3_03[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row29[0].c3_04[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row29[0].c3_05[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row29[0].c3_06[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for May.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row29[0].c3_07[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for June.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row29[0].c3_08[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for July.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row29[0].c3_09[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for August.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row29[0].c3_10[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for September.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row32[0].c3_41[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row32[0].c3_42[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row32[0].c3_43[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row32[0].c3_44[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row32[0].c3_45[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for May.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row32[0].c3_46[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for June.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row32[0].c3_47[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for July.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row32[0].c3_48[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for August.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row32[0].c3_49[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for September.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row38[0].c3_119[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row38[0].c3_120[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row38[0].c3_121[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row38[0].c3_122[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row38[0].c3_123[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for May.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row38[0].c3_124[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for June.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row38[0].c3_125[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for July.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row38[0].c3_126[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for August.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row38[0].c3_127[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for September.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row40[0].c3_145[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for January.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row40[0].c3_146[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for February.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row40[0].c3_147[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for March.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row40[0].c3_148[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for April.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row40[0].c3_149[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for May.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row40[0].c3_150[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for June.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row40[0].c3_151[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for July.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row40[0].c3_152[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for August.
|
| topmostSubform[0].Page3[0].Table2_Part4[0].Row40[0].c3_153[0]_1 | CheckBox |
Indicate whether the individual had minimum essential health coverage for September.
|
| Employer Information | ||
| 10 Employer name | Text |
Enter the name of the employer providing the health coverage.
|
| 11 Employer identification number (EIN) | Text |
Enter the Employer Identification Number (EIN) of the employer providing the health coverage. This should be a 9-digit number.
|
| 12 Street address (including room or suite no.) | Text |
Enter the street address of the employer, including room or suite number if applicable.
|
| 13 City or town | Text |
Enter the city or town where the employer is located.
|
| 15 Country and ZIP or foreign postal code | Text |
Enter the country and ZIP or foreign postal code of the employer's address.
|
| General Information | ||
| 9 Reserved | Text |
This field is reserved for future use and should be left blank.
|
| topmostSubform[0].Page1[0].f1_16[0 | Text |
This field appears to be incomplete or incorrectly labeled. Please verify the form for the correct field name and purpose.
|
| number (EIN) | Text |
This field appears to be incomplete or incorrectly labeled. Please verify the form for the correct field name and purpose.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row23[0].f1_25[0 | Text |
This field appears to be incomplete or incorrectly labeled. Please verify the form for the correct field name and purpose.
|
| Individual Identification | ||
| topmostSubform[0].Page1[0].Table1_Part4[0].Row25[0].f1_39[0 | Text |
Enter the Social Security Number (SSN) or Tax Identification Number (TIN) of the individual. This should be up to 10 characters long.
|
| Issuer or Coverage Provider | ||
| topmostSubform[0].Page3[0].Table2_Part4[0].Row35[0].f3_40[0 | Text |
Enter the policy number associated with the covered individual's health coverage.
|
| Monthly Coverage | ||
| topmostSubform[0].Page1[0].Table1_Part4[0].Row25[0].c1_27[0]_1 | CheckBox |
Check this box if the individual had coverage for the month of January.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row25[0].c1_28[0]_1 | CheckBox |
Check this box if the individual had coverage for the month of February.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row25[0].c1_29[0]_1 | CheckBox |
Check this box if the individual had coverage for the month of March.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row25[0].c1_30[0]_1 | CheckBox |
Check this box if the individual had coverage for the month of April.
|
| topmostSubform[0].Page1[0].Table1_Part4[0].Row25[0].c1_31[0]_1 | CheckBox |
Check this box if the individual had coverage for the month of May.
|
| Policy Information | ||
| topmostSubform[0].Page1[0].Table1_Part4[0].Row25[0].f1_38[0 | Text |
Enter the policy number associated with the individual's health coverage. This should be up to 11 characters long.
|
| Responsible Individual | ||
| topmostSubform[0].Page1[0].Part1Contents[0].Line1[0].f1_01[0 | Text |
Enter the name of the responsible individual who had health coverage.
|
| 2 Social security number (SSN) or other TIN | Text |
Enter the Social Security Number (SSN) or other Tax Identification Number (TIN) of the responsible individual.
|
| 3 Date of birth (if SSN or other TIN is not available) | Date |
Enter the date of birth of the responsible individual if SSN or TIN is not available.
|
| 4 Street address (including apartment no.) | Text |
Enter the street address, including apartment number, of the responsible individual.
|
| 5 City or town | Text |
Enter the city or town of the responsible individual's address.
|
| 6 State or province | Text |
Enter the state or province of the responsible individual's address.
|
| 7 Country and ZIP or foreign postal code | Text |
Enter the country and ZIP or foreign postal code of the responsible individual's address.
|
| topmostSubform[0].Page3[0].Name_ReadOrder[0].f3_01[0 | Text |
Enter the name of the responsible individual for the health coverage.
|
| topmostSubform[0].Page3[0].Name_ReadOrder[0].f3_02[0 | Text |
Enter the name of the responsible individual for the health coverage.
|
| Social security number (SSN) or other TIN | Text |
Enter the Social Security Number (SSN) or other Tax Identification Number (TIN) of the responsible individual.
|
| Date of birth (if SSN or other TIN is not available) | Date |
Enter the date of birth of the responsible individual if SSN or other TIN is not available.
|
| Responsible Individual Information | ||
| 16 Name | Text |
Enter the name of the responsible individual or entity for the health coverage.
|
| 17 Employer identification number (EIN) | Text |
Enter the Employer Identification Number (EIN) of the responsible individual or entity. This should be a 9-digit number.
|
| 19 Street address (including room or suite no.) | Text |
Enter the street address of the responsible individual or entity, including room or suite number if applicable.
|
| 20 City or town | Text |
Enter the city or town where the responsible individual or entity is located.
|
| 21 State or province | Text |
Enter the state or province where the responsible individual or entity is located.
|
| 22 Country and ZIP or foreign postal code | Text |
Enter the country and ZIP or foreign postal code of the responsible individual's or entity's address.
|