|
Field Name | Size | Type | Description | Notes |
|---|---|---|---|---|
| See Form Filer Common Fields | ||||
| See Recipient Common Fields | ||||
| Record Type | 1 | Text | Record Type is a required field and it indicates if a record is the Employee Record or the Covered Individual record. Use E for employee & C for Covered Individual | Use E for employee & C for Covered Individual |
| Rcp Email | 65 | Text | ||
| Rcp IMB | 65 | Text | ||
| Tax State | 2 | Text | ||
| Emp TIN | 11 | Numeric | Part II: Employer EIN | |
| Emp TIN Type | 1 | Numeric | Part II: Employer TIN Type | EIN=1, SSN=2, Unknown type=0 or blank |
| Emp Address Type | 1 | Text | Part II: Employer Address Type | |
| Emp Country Code | 2 | Text | Part II: Country Code | |
| Emp Country Key | 1 | Numeric | Part II: Country Key | |
| Emp Name 1 | 40 | Text | Part II: Employer Name 1 | |
| Emp Name 2 | 40 | Text | Part II: Employer Name 2 | |
| Emp Address 1 | 40 | Text | Part II: Employer Street Address | |
| Emp Address 2 | 40 | Text | Part II: Employer Suite/Apt | |
| Emp City | 40 | Text | Part II: City | |
| Emp State | 23 | Text | Part II: Employer State/Province | |
| Emp Zip | 15 | Text | Part II: Employer Zip/Postal Code | |
| Rcp Date of Birth | 8 | Date | Recipient date of birth | MM/DD/YYYY or M/D/YYYY |
| Policy Origin Code | 2 | Text | Letter identifying the origin of the policy | A, B, C, D, E, F and G are valid codes |
| Ind All Coverage Chk | 1 | Checkbox | Individual: Covered all 12 months checkbox | X / Y / T / 1 = Checked |
| Ind Apr Coverage Chk | 1 | Checkbox | Individual: Covered for April checkbox | X / Y / T / 1 = Checked |
| Ind Aug Coverage Chk | 1 | Checkbox | Individual: Covered for August checkbox | X / Y / T / 1 = Checked |
| Ind Dec Coverage Chk | 1 | Checkbox | Individual: Covered for December checkbox | X / Y / T / 1 = Checked |
| Ind Feb Coverage Chk | 1 | Checkbox | Individual: Covered for February checkbox | X / Y / T / 1 = Checked |
| Ind Jan Coverage Chk | 1 | Checkbox | Individual: Covered for January checkbox | X / Y / T / 1 = Checked |
| Ind Jul Coverage Chk | 1 | Checkbox | Individual: Covered for July checkbox | X / Y / T / 1 = Checked |
| Ind Jun Coverage Chk | 1 | Checkbox | Individual: Covered for June checkbox | X / Y / T / 1 = Checked |
| Ind Mar Coverage Chk | 1 | Checkbox | Individual: Covered for March checkbox | X / Y / T / 1 = Checked |
| Ind May Coverage Chk | 1 | Checkbox | Individual: Covered for May checkbox | X / Y / T / 1 = Checked |
| Ind Nov Coverage Chk | 1 | Checkbox | Individual: Covered for November checkbox | X / Y / T / 1 = Checked |
| Ind Oct Coverage Chk | 1 | Checkbox | Individual: Covered for October checkbox | X / Y / T / 1 = Checked |
| Ind Sep Coverage Chk | 1 | Checkbox | Individual: Covered for September checkbox | X / Y / T / 1 = Checked |
