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{"sheet":"Instructions","index":0,"n_rows":25,"n_cols":2,"rows_kept":25,"cut":false,"hidden":false,"merged":[]}
["Timeline:","Once plans are selected, we recommend allowing two weeks for applications to be processed in order to receive final rates prior to the requested effective date."]
[null,"*Please note: applications submitted with less than two weeks lead time, may not receive approval/final rates until after the effective date (in some cases, you may experience a delay of as much as 10 business days)."]
["Instructions:","The following fields MUST be completed in full for All Eligible Employees."]
["Employee Record #","Used to number only the Employees (no number here for Spouse or Child)\n"]
["Associated w Employee Record #","Blank for Employee.\nPut the number corresponding to the Employee Record # in this field when Spouse or Child "]
["*Relationship","Employee\nSpouse\nChild\n"]
["Last Name"]
["First Name"]
["DOB","Type MMDDYY\n"]
["Gender","Male or Female"]
["Home Zip"]
["Work Zip"]
["Medical","EE - Employee Only\nES - Employee + Spouse\nEC - Employee + Child\nEF - Employee + Spouse + Child\nW - Waiving Coverage"]
["Dental","EE - Employee Only\nES - Employee + Spouse\nEC - Employee + Child\nEF - Employee + Spouse + Child\nW - Waiving Coverage"]
["Vision","EE - Employee Only\nES - Employee + Spouse\nEC - Employee + Child\nEF - Employee + Spouse + Child\nW - Waiving Coverage"]
["Life","EE - Employee Only\nES - Employee + Spouse\nEC - Employee + Child\nEF - Employee + Spouse + Child\nW - Waiving Coverage"]
["Life Volume"]
["Disability"]
["Annual Salary\n(est if hrly)","Required Only if you are insterested in obtaining quotes for Group Disability\nOR\nSalary Based Life Insurance\nAnnual Salary: required ONLY if you are interested in obtaining quotes for Group Disability, or salary based Life Insurance.\nFor hourly employees, provide estimate of annual salary.\nFor commissioned employees, provide previous year's total salary including commission OR (if not available) estimated amt for current year."]
[" # Children\n"]
["Medicare Enrollee"]
["Cobra or State Continuation"]
["Smoker"]
["Retired"]
["Disabled"]

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[null,null,null,"Please Note: This is ONLY used for obtaining quotes.  It is NOT used to process OR initiate enrollment changes (including employee additions, deletions or changes in employee status).\nNor is it acceptable as a request or authorization to make such changes.\nINSTRUCTIONS: Move mouse over the Header of each Column OR located on Worksheet 2 (Instructions Tab)"]
[]
[null,null,null,"Date of Census:",null,null,null,null,null,"*Requested Effective Date:"]
[null,null,null,"Co Name:",null,null,null,null,null,"Bus. Description:"]
[null,null,null,"SIC Code:"]
[null,null,null,"Contact Name:"]
[null,null,null,"Address:",null,null,null,null,null,"City/State:",null,null,null,null,"Zip Code:"]
[null,null,null,"Telephone:",null,null,null,null,null,"Fax:",null,null,"Email:"]
[null,null,null,"Current Carrier:",null,null,null,null,null,null,null,null,null,"Avg # Emp:"]
[null,null,null,"Requested Benefits:",null,null,null,null,null,null,null,null,null,null,"Current Benefits(Dr Copay/RX Copay/ Ded / CoInsurance):"]
[]
["Employee Record #","Associated w Employee Record #","*Relationship","Last Name","First Name","DOB","Gender","Home Zip","Work Zip","Medical","Dental","Vision","Life","* Life Volume","Disability","**Annual Salary\n(est if hrly)"," # Children\n","Medicare Enrollee","Cobra or State Continuation","Smoker","Retired","Disabled"]
[1]