| # | Id | Type | Description |
| 1 | marketplaceId | string | Box 1, Marketplace identifier |
| 2 | marketplacePolicyNumber | string | Box 2, Marketplace-assigned policy number |
| 3 | policyIssuerName | string | Box 3, Policy issuer's name |
| 4 | recipientDateOfBirth | DateString | |
| 5 | spouseName | string | Box 7, Recipient's spouse's name |
| 6 | spouseTin | string | Box 8, Recipient's spouse's SSN |
| 7 | spouseDateOfBirth | DateString | |
| 8 | policyStartDate | DateString | |
| 9 | policyTerminationDate | DateString | |
| 10 | coveredIndividuals | Array of HealthInsuranceMarketplaceCoveredIndividual | Boxes 16+, Covered Individuals |
| 11 | coverages | Array of HealthInsuranceCoverage | Boxes 21-33, Coverage Information |