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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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