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Employee SSN Dependent SSN Last Name First 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 office location Eligibility Department Divisions Start Date Employment Status carrier product effective start date effective end date plan name coverage level employee monthly cost employee per pay cost company monthly cost company per pay cost approved benefit amount enrollment type enrolled date Enrolled By
111-22-4726 Adkins Ada Employee Female 07/15/1991 No 650 Redwood Road Oakland CA 95004 US 789-980-0009 abc1394@gmail.com California Full Time Engineering Packing & Printing 06/02/1999 Active Anthem Blue Cross Medical 10/01/2019 01/01/2020 Anthem Gold $1000 PPO Employee $187.50 $86.54 $187.50 $86.54 Open Enrollment Kaylin Lewis
111-22-4726 Adkins Ada Employee Female 07/15/1991 No 650 Redwood Road Oakland CA 95004 US 789-980-0009 abc1394@gmail.com California Full Time Engineering Packing & Printing 06/02/1999 Active Delta Dental of Massachusetts Dental 10/01/2019 01/01/2020 Delta Dental PPO Employee $10.00 $4.62 $10.00 $4.62 Open Enrollment Kaylin Lewis
111-22-4726 Adkins Ada 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 Health Savings Account (HSA) Qualified Life Event 01/20/2020 Kaylin Lewis
111-22-4726 Adkins Ada Employee Female 07/15/1991 No 650 Redwood Road Oakland CA 95004 US 789-980-0009 abc1394@gmail.com California Full Time Engineering Packing & Printing 06/02/1999 Active ASIFlex Dependent Care FSA 10/01/2019 01/01/2020 Flexible Spending Account - Dependent Care Employee $16.67 $7.14 Open Enrollment Kaylin Lewis
111-22-4726 Adkins Ada Employee Female 07/15/1991 No 650 Redwood Road Oakland CA 95004 US 789-980-0009 abc1394@gmail.com California Full Time Engineering Packing & Printing 06/02/1999 Active EyeMed Vision 10/01/2019 01/01/2020 EyeMed Vision Employee $7.50 $3.46 $7.50 $3.46 Open Enrollment Kaylin Lewis
111-22-3359 Allen Elissa Employee Male 02/04/1978 No 650 Redwood Road Oakland CA 95004 US 789-980-0009 abc27@gmail.com Maryland Full Time Production Online Services 09/25/2019 Active Voluntary Life AD&D New Hire 10/24/2019 Kaylin Lewis
111-22-3359 Allen Elissa Employee Male 02/04/1978 No 650 Redwood Road Oakland CA 95004 US 789-980-0009 abc27@gmail.com Maryland Full Time Production Online Services 09/25/2019 Active Anthem Blue Cross Medical 10/01/2019 01/01/2020 Anthem PPO 4000 HSA Employee + Spouse $100.00 $46.15 $200.00 $92.31 New Hire 10/24/2019 Kaylin Lewis
111-22-3359 Allen Elissa Employee Male 02/04/1978 No 650 Redwood Road Oakland CA 95004 US 789-980-0009 abc27@gmail.com Maryland Full Time Production Online Services 09/25/2019 Active Guardian Group Short Term Disability 10/01/2019 01/01/2024 Guardian Group STD Employee $15.92 $7.35 692.00 New Hire 10/24/2019 Kaylin Lewis
111-22-3359 Allen Elissa Employee Male 02/04/1978 No 650 Redwood Road Oakland CA 95004 US 789-980-0009 abc27@gmail.com Maryland Full Time Production Online Services 09/25/2019 Active Delta Dental of Massachusetts Dental 12/01/2019 01/01/2020 Delta Dental PPO Employee + Spouse $25.00 $11.54 $10.00 $4.62 New Hire 10/24/2019 Kaylin Lewis
111-22-3359 Allen Elissa Employee Male 02/04/1978 No 650 Redwood Road Oakland CA 95004 US 789-980-0009 abc27@gmail.com Maryland Full Time Production Online Services 09/25/2019 Active EyeMed Vision 12/01/2019 01/01/2020 EyeMed Vision Employee + Spouse $12.50 $5.77 $7.50 $3.46 New Hire 10/24/2019 Kaylin Lewis
111-22-3359 Allen Elissa Employee Male 02/04/1978 No 650 Redwood Road Oakland CA 95004 US 789-980-0009 abc27@gmail.com Maryland Full Time Production Online Services 09/25/2019 Active Guardian Group Long Term Disability 10/01/2019 01/01/2024 Guardian Group LTD Employee $10.50 $4.85 3,000.00 New Hire 10/24/2019 Kaylin Lewis
111-22-3359 Allen Elissa Employee Male 02/04/1978 No 650 Redwood Road Oakland CA 95004 US 789-980-0009 abc27@gmail.com Maryland Full Time Production Online Services 09/25/2019 Active Guardian Group Life AD&D 10/01/2019 01/01/2024 Guardian Group Life/AD&D Employee $7.50 $3.46 50,000.00 New Hire 10/24/2019 Kaylin Lewis
111-22-3359 Allen Elissa Employee Male 02/04/1978 No 650 Redwood Road Oakland CA 95004 US 789-980-0009 abc27@gmail.com Maryland Full Time Production Online Services 09/25/2019 Active Commuter New Hire 10/24/2019 Kaylin Lewis
111-22-3359 Allen Elissa Employee Male 02/04/1978 No 650 Redwood Road Oakland CA 95004 US 789-980-0009 abc27@gmail.com Maryland Full Time Production Online Services 09/25/2019 Active Dependent Care FSA New Hire 10/24/2019 Kaylin Lewis
111-22-3359 548-69-7485 allen matt Spouse Male 09/18/1978 No 650 Redwood Road Oakland CA 95004 US Full Time Production Online Services 09/25/2019 EyeMed Vision 12/01/2019 01/01/2020 EyeMed Vision Employee + Spouse New Hire 10/24/2019 Kaylin Lewis
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