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Employee SSN Full Name Dependent SSN First Name Last Name relationship suffix gender Date of Birth tobacco home address addr1 home address addr2 home address city home address state home address zip home address county home address country phone email work locations Eligibility Department Divisions Start Date termination date termination reason Employment Status enrollment type carrier product enrollment start date enrollment end date plan name coverage level employee monthly cost employee per pay cost company monthly cost company per pay cost approved benefit amount effective date change by
111-22-4726 Ada Adkins Ada Adkins Employee Female 07/15/1991 No 650 Redwood Road Oakland CA 95004 Alemeda US 789-980-0009 abc1394@gmail.com California Full Time Engineering Packing & Printing 06/02/1999 Active Qualified Life Event Guardian Group Long Term Disability 01/17/2020 02/16/2020 Guardian Group LTD Employee $10.50 $4.85 3,000.00 01/20/2020 Kaylin Lewis
111-22-4726 Ada Adkins Ada Adkins Employee Female 07/15/1991 No 650 Redwood Road Oakland CA 95004 Alemeda US 789-980-0009 abc1394@gmail.com California Full Time Engineering Packing & Printing 06/02/1999 Active Qualified Life Event Unum Group Voluntary Life AD&D 01/17/2020 02/16/2020 2019 UNUM Voluntary Life/AD&D Employee + Spouse $76.00 $35.07 250,000.00 01/20/2020 Kaylin Lewis
111-22-4726 Ada Adkins Ada Adkins Employee Female 07/15/1991 No 650 Redwood Road Oakland CA 95004 Alemeda US 789-980-0009 abc1394@gmail.com California Full Time Engineering Packing & Printing 06/02/1999 Active Qualified Life Event Guardian Group Short Term Disability 01/17/2020 02/16/2020 Guardian Group STD Employee $15.92 $7.35 692.00 01/20/2020 Kaylin Lewis
111-22-4726 Ada Adkins Ada Adkins Employee Female 07/15/1991 No 650 Redwood Road Oakland CA 95004 Alemeda US 789-980-0009 abc1394@gmail.com California Full Time Engineering Packing & Printing 06/02/1999 Active Qualified Life Event Cigna Dental 01/17/2020 02/16/2020 Cigna Dental PPO Employee $40.00 $18.46 01/20/2020 Kaylin Lewis
111-22-4726 Ada Adkins Ada Adkins Employee Female 07/15/1991 No 650 Redwood Road Oakland CA 95004 Alemeda US 789-980-0009 abc1394@gmail.com California Full Time Engineering Packing & Printing 06/02/1999 Active Qualified Life Event Anthem Blue Cross Medical 01/17/2020 02/16/2020 Anthem Gold $1000 PPO - 2020 Employee + Spouse $281.25 $129.81 $218.75 $100.96 01/20/2020 Kaylin Lewis
111-22-4726 Ada Adkins Ada Adkins Employee Female 07/15/1991 No 650 Redwood Road Oakland CA 95004 Alemeda US 789-980-0009 abc1394@gmail.com California Full Time Engineering Packing & Printing 06/02/1999 Active Qualified Life Event Guardian Group Life AD&D 01/17/2020 02/16/2020 Guardian Group Life/AD&D Employee $7.50 $3.46 50,000.00 01/20/2020 Kaylin Lewis
111-22-4726 Ada Adkins 563-31-4896 Stephen Adkins Spouse Male 03/22/1990 No 650 Redwood Road Oakland CA 95004 Alemeda US 789-980-0009 abc1394@gmail.com Full Time Engineering Packing & Printing 06/02/1999 Qualified Life Event Unum Group Voluntary Life AD&D 01/17/2020 02/16/2020 2019 UNUM Voluntary Life/AD&D Employee + Spouse $76.00 $35.07 150,000.00 01/20/2020 Kaylin Lewis
111-22-4726 Ada Adkins 563-31-4896 Stephen Adkins Spouse Male 03/22/1990 No 650 Redwood Road Oakland CA 95004 Alemeda US 789-980-0009 abc1394@gmail.com Full Time Engineering Packing & Printing 06/02/1999 Qualified Life Event Anthem Blue Cross Medical 01/17/2020 02/16/2020 Anthem Gold $1000 PPO - 2020 Employee + Spouse $281.25 $129.81 $218.75 $100.96 01/20/2020 Kaylin Lewis
Allison Bale Employee Female 05/01/1979 No 35145 Newark Boulevard Newark CA 94560 Alameda County US California 07/02/2019 Active New Hire Guardian Group Life AD&D 12/26/2019 01/25/2020 Guardian Group Life/AD&D Employee $7.50 $3.46 50,000.00 12/30/2019 Kaylin Lewis
Allison Bale Employee Female 05/01/1979 No 35145 Newark Boulevard Newark CA 94560 Alameda County US California 07/02/2019 Active New Hire ASIFlex Dependent Care FSA 12/26/2019 01/25/2020 Flexible Spending Account - Dependent Care Employee $40.00 $18.18 12/30/2019 Kaylin Lewis
Allison Bale Employee Female 05/01/1979 No 35145 Newark Boulevard Newark CA 94560 Alameda County US California 07/02/2019 Active New Hire EyeMed Vision 12/26/2019 01/25/2020 EyeMed Vision Employee $7.50 $3.46 $7.50 $3.46 12/30/2019 Kaylin Lewis
Allison Bale Employee Female 05/01/1979 No 35145 Newark Boulevard Newark CA 94560 Alameda County US California 07/02/2019 Active New Hire Unum Group Voluntary Life AD&D 12/26/2019 01/25/2020 2019 UNUM Voluntary Life/AD&D Employee $47.50 $21.92 250,000.00 12/30/2019 Kaylin Lewis
Allison Bale Employee Female 05/01/1979 No 35145 Newark Boulevard Newark CA 94560 Alameda County US California 07/02/2019 Active New Hire Anthem Blue Cross Medical 12/26/2019 01/25/2020 Anthem Gold $1000 PPO Employee $187.50 $86.54 $187.50 $86.54 12/30/2019 Kaylin Lewis
Allison Bale Employee Female 05/01/1979 No 35145 Newark Boulevard Newark CA 94560 Alameda County US California 07/02/2019 Active New Hire Guardian Group Short Term Disability 12/26/2019 01/25/2020 Guardian Group STD Employee $26.54 $12.25 1,154.00 12/30/2019 Kaylin Lewis
Allison Bale Employee Female 05/01/1979 No 35145 Newark Boulevard Newark CA 94560 Alameda County US California 07/02/2019 Active New Hire Guardian Group Long Term Disability 12/26/2019 01/25/2020 Guardian Group LTD Employee $17.50 $8.08 5,000.00 12/30/2019 Kaylin Lewis
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