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Mapping the 1095-C Excel Template to the Form for Easier Data Input

Here is a mapping tool to use when entering data into the 1095-C Excel Template:

Column A – Form Type

Column B-J – Part I:  Applicable Large Employer Member (Employer)

Column K-T – Part I:  Employee

Column U - Part II:  Plan Start Month

Column V-AH – Part II:  Line 14 – Offer of Coverage

Column AI-AU – Part II:  Line 15 – Employee Share of Lowest Cost Monthly Premium, for Self-Only Minimum Value Coverage

Column AV-BH – Part II:  Line 16 – Applicable Section 4980HSafe Harbor (enter code if applicable)

Column BI – Part III: Covered Individuals – Check box if employer provided self-insured coverage 

Column BJ-BY – Part III:  First Covered Individual (Name, SSN or DOB and months of coverage)

Column BZ-CO – Part III:  Second Covered Individual (Name, SSN or DOB and months of coverage)

Column CP-DE – Part III:  Third Covered Individual (Name, SSN or DOB and months of coverage)

Column DF-DU – Part III:  Fourth Covered Individual (Name, SSN or DOB and months of coverage)

Column DV-EK – Part III:  Fifth Covered Individual (Name, SSN or DOB and months of coverage)

Column EL-FA – Part III:  Sixth Covered Individual (Name, SSN or DOB and months of coverage)

Column FB-FQ – Part III:  Seventh Covered Individual (Name, SSN or DOB and months of coverage)

Column FR-GG – Part III:  Eighth Covered Individual (Name, SSN or DOB and months of coverage)

Column GH-GW – Part III:  Ninth Covered Individual (Name, SSN or DOB and months of coverage)

Column GX-HM – Part III:  Tenth Covered Individual (Name, SSN or DOB and months of coverage)

Column HN-IC – Part III:  Eleventh Covered Individual (Name, SSN or DOB and months of coverage)

Column ID-IS – Part III:  Twelfth Covered Individual (Name, SSN or DOB and months of coverage)

Column IT-JI – Part III:  Thirteenth Covered Individual (Name, SSN or DOB and months of coverage)

Column JJ-JY – Part III:  Fourteenth Covered Individual (Name, SSN or DOB and months of coverage)

Column JZ-KO – Part III:  Fifteenth Covered Individual (Name, SSN or DOB and months of coverage)

Column KP-LE – Part III: Sixteenth Covered Individual (Name, SSN or DOB and months of coverage)

Column LF-LU – Part III: Seventeenth Covered Individual (Name, SSN or DOB and months of coverage)

Column LV-MK – Part III:  Eighteenth Covered Individual (Name, SSN or DOB and months of coverage)

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