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Employee Data Sheet
Date
form submitted________________________
Submitted by_____________________
E-Mail Address_______________________________
Employer_______________________________________________
Group Number________________________________
Location______________________________
Employee Name_______________________________________
Gender ____________
Social Security Number____________________________
Date
of Birth________________________
Hire Date _____________________
Employee's
Address_____________________________________________________________
_______________________________________________________________________________
City_____________________________
State___________________ Zip Code _________________
Employee's Telephone Numbers:
Home_____________________________
Work _____________________________
Coverage applying for ___ Individual; ___ Family
If Other coverage, please explain___________________________________________________
Type of Coverage (select ALL that apply):
____ Medical
____ Dental
____ Vision
____ EAP - Employee Assistance Program
____ FSA - Flexible Spending Account
____
Other (please
explain)________________________________________________________
Effective Date of Coverage___________________________________
Qualifying Event Date________________________________________
Qualifying Event Code______
(T = Terminated; R = Resignation; RT = Retirement; RH = Reduction of Hours; D = Death;
DV = Divorce; LS = Legal Separation; DI = Dependent Ineligible; ME = Medicare Entitlement;
EL = Eligible Leave; DIS = Disability)
Transaction Code______
(E = New Enrollment; TC = Terminated; DC = Dropped Coverage; AD = Add Dependent(s);
DD = Drop Dependent(s); CS = Change Status - explain)
Change Status
Explanation_________________________________________________________
Terminated Employee's Address (if COBRA eligible ONLY)
________________________________________________________________________________
________________________________________________________________________________
Flexible Spending Amount $_______________________________
DEPENDENT
INFORMATION
Name___________________________ Gender____ DOB_____________
Relationship_________
Name___________________________ Gender____ DOB_____________
Relationship_________
Name___________________________ Gender____ DOB_____________
Relationship_________
Name___________________________ Gender____ DOB_____________
Relationship_________
Name___________________________ Gender____ DOB_____________
Relationship_________
Name___________________________ Gender____ DOB_____________
Relationship_________
Is Employee Covered by any other insurance plan? ____________
If Yes, what company?
_____________________________________________________________
Additional
Information
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________