Employee Name*
Date of Birth*
MM/DD/YY
Gender*
Coverage*
# of Children*
EE
EE/Spouse
Family
EE/Child
M F
M F
M F
M F
M F
M F
M F
M F
M F
M F
M F
M F
M F
M F
M F
M F
M F
M F
M F
M F