First Name
Last Name
ID
Gender	choose one Male Female
DOB	mm/dd/yyyy
Status	choose one Active Cobra FT Full Time OC Other Coverage Part Time PT WC Waiving Coverage Waiting Period WP
Earnings (year)
Occupation
Zip Code
Date of Hire
Is Eligible	choose one Yes No
Spouse	choose one Yes No
Spouse DOB	mm/dd/yyyy
# of Children
Email
Medical	Employee Only Employee + 1 Employee + 2 or more Employee + Spouse Employee + Child Employee + Children Family
Dental	Employee Only Employee + 1 Employee + 2 or more Employee + Spouse Employee + Child Employee + Children Family
Life	Employee Only Employee + 1 Employee + 2 or more Employee + Spouse Employee + Child Employee + Children Family
Other	Employee Only Employee + 1 Employee + 2 or more Employee + Spouse Employee + Child Employee + Children Family