Employer Information

Employer Name: Date of Hire: Effective Date of Coverage:

Corporate Solutions Incorporated 02/04/2016 07/01/2017
Employee Information
Last name First Name Middle Initial Date of Birth Social Security#
Dentist John G 04/05/1981 123-45-6789
Home Mailing Address Street Apt# City State Zip Code
123 Apple Street N/A San Antonio TX 78216
Home Phone# E-Mail Address Gender Height Weight Tobacco User
123-456-7890 john.dentist@email.com Male D Yes ,grNo
- 6'0" 1751bs
Plan Selection (if applicable): Marital Status: D Single Married (date: 08/13/2002 ) D Divorced (date: )
$1500 Deductible Plan D Separated (date: ) D Widowed (date: )
If Applying for Dependent Coverage, Complete Section Below for all Dependents to be Covered:

First Name Last Name Step- Gender Date of Height Weight Tobacco Social Security
& Middle Initial (if different from Child Birth User Number
applicant) (Yes or No)
Sp Jennifer A. N/A N/A Female 07/22/1984 5' 7" 1301bs No 176-76-2692
Ch1 Thomas S. N/A No Male 12/16/2004 5' 6" 1221bs No 792-82-8746
Ch2 Madeline T. N/A No Female 04/26/2014 31.4" 261bs No 916-472-9052
Ch3
Ch4