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Demographic Information

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  Enrollee: DIV: ELK Group: 22222 Insured ID:
         
Employee Information
 Demographic Information
Product Information
Other Insurance (optional)
COBRA (optional)
                 
Step 3 Enter Demographic Information and Continue.
*Required Fields
 
  Original Effective* 02/01/2002
Termination
Last Updated    
   
 

Employee ID*
SSN - -

Date of Birth * / /
Relationship EMPLOYEE

Last Name*

First Name*
MI  

Address 1*

Address 2

City*

State*
Zip* -

Home Phone - -
Work Phone - -

Gender*
Marital Status*

Wait Period*
Wait Begin Date* / /
 
  
 

Enter/choose the following data on the sample page.
 
  • Employee ID=555666777
  • Date of Birth=12/18/1971
  • Last Name=Quinn
  • First Name=Carmel
  • Address 1=1234 Shady Oak Drive
  • City=Anytown
  • State=Wisconsin
  • Zip=54546
  • Home Phone=715-555-4444
  • Gender=Female
  • Marital Status=Single
  • Wait Period=N
   
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