| Edit Enrollment Information | Edit Doctor Selection |
|
| Primary Member |
Jack Smith |
| Address |
123 Knoll Crest Rd
Mt. Washington, NH 03555
United States |
| Primary Phone # |
603-999-9999 |
| Secondary Phone # |
|
| E-mail |
smithfamily@atti.net |
| Date of Birth |
09/25/1968 |
| Gender |
Male |
| Relation to primary member |
Self |
| Doctor |
Paul Ashcroft, MD |
| |
|
| |
| Coverage Elections |
| Medical |
| 01/01/2007-12/31/2007 |
|
| Dental |
| 01/01/2007-12/31/2007 |
|
| Flexible Spending Account |
| 01/01/2007-12/31/2007 |
|
| Disability |
| 01/01/2007-12/31/2007 |
|
| Life Insurance |
| 01/01/2007-12/31/2007 |
|
|
| |
| Dependent |
Jane Smith |
| Date of Birth |
02/03/1968 |
| Gender |
Female |
| Relation to primary member |
Spouse |
| Full-time student |
No |
| Disabled |
No |
| Doctor |
Amy Scott, MD |
| |
|
| |
| Coverage Elections |
| Medical |
| 01/01/2007-12/31/2007 |
|
| Dental |
| 01/01/2007-12/31/2007 |
|
|
|
| |
| Dependent |
Josh Smith |
| Date of Birth |
02/03/1987 |
| Gender |
Male |
| Relation to primary member |
Child |
| Full-time student |
Yes |
| Disabled |
No |
| Doctor |
Paul Ashcroft, MD |
| |
|
| |
| Coverage Elections |
| Medical |
| 01/01/2007-12/31/2007 |
|
|
|
| |
| Other Coverage |
|
| Name of other healthplan |
ABC Healthplan |
| |
| Transferring Coverage |
|
| Name of transferring plan |
XYZ Company |
| |
|