Active Employees
Please list all active employees, if they will be including spouse or dependent children please entre under "name" spouse, son or daughter and give the date of birth. An employee may use your business zip code for residence zip code. Note: If an employee is not participating please give an explanation: Part Time (PT), Insured With Spouse (IWS), Own Individual Policy (OWN), Other Health Program (OHP), Ineligible or Declined.
Health Insurance Category:
EE Only - Employee Enrollment Only
EE+Spouse - Employee and Child or Children
EE+Dependent -- Employee and Child or Children
Family - Employee, Spouse and Child or Children
If life benefit is included, please list those who qualify for life benefit but are not enrolling in the health plan.
Life Insurance Category for those not enrolling in Health Benefit:
Life EE Only; Life EE+Spouse, Life EE+Dependents; Life Family
On each line, include:
Name, Sex, DOB, Category, # Dependent Children, Hire Date, Resident Zip Code
Without disclosing names, please list any known medical conditions in groub and how long condition has existed.
