Effective July 1, 2011


Enrollee Information

Dependent Information

Social Security NumberSocial Security Number
First NameRelationship (Dependent, Spouse, Former Spouse)
Middle InitialFirst Name
Last NameMiddle Initial
GenderLast Name
Primary Address 1Gender
Primary Address 2Date of Birth
Primary Address 3Primary Address 1 (if former spouse)
CityPrimary Address 2 (if former spouse)
StatePrimary Address 3 (if former spouse)
Zip codeCity (if former spouse)
Zip plus 4State (if former spouse)
Foreign City/CountryZip Code (if former spouse)
Date of BirthZip plus 4 (if former spouse and available)
Date of Retirement (only if retired status)Home phone area code (if former spouse and available)
Date into Service (only if active status)Home phone number (if former spouse and available)
Status (Active, Retired, Survivor, COBRA) 
Home phone area code (if available) 
Home phone number (if available) 
Business phone area code (if available) 
Business phone number (if available) 
Business phone extension (if available) 
COBRA start date (only if COBRA status) 
COBRA end date (only if COBRA status) 
Hours worked (only if active status) 
Department (only if active status) 

Supported File Formats

Excel comma separated file*


* file layouts on separate document


This information provided by the Group Insurance Commission .