1095-A | Health Insurance

1095-A

Email:

Full Name:

1 Marketplace identifier

2 Marketplace-assigned policy number

3 Policy issuer’s name

4 Recipient’s name

5 Recipient’s SSN

6 Recipient’s date of birth

7 Recipient’s spouse’s name

8 Recipient’s spouse’s SSN

9 Recipient’s spouse’s date of birth

10 Policy start date

11 Policy termination date

12 Street address (including apartment no.)

13 City or town

14 State or province

15 Country and ZIP or foreign postal code

A. Covered individual name	B. Covered individual SSN	C. Covered individual date of birth	D. Coverage start date E	E. Coverage termination date
16.
17.
18.
19.
20.

Month	A. Monthly enrollment premiums	B. Monthly second lowest cost silver plan (SLCSP) premium	C. Monthly advance payment of premium tax credit
21 January
22 February
23 March
24 April
25 May
26 June
27 July
28 August
29 September
30 October
31 November
32 December
33 Annual Total