Administrative Bulletin  Required Municipal Initial Enrollment Data

Date:	07/01/2011
Referenced Sources:	Group Insurance Commission

Enrollee Information

Municipalities are required to submit this data to the GIC in the format specified by GIC staff in order to ensure this data is sent securely.

Enrollee Data
First Name
Middle Initial
Last Name
Social Security Number
Sex
Date of Birth
Employment Status (Active, Retired, Survivor)
Address 1
Address 2
Address 3
City
State
Zip code
Zip Extension
Country
Preferred Phone Number
Preferred Email
Hire Date (only if active status)
Retirement Date (only if retired status)
Number of hours worked (only if active status)
COBRA end date (only if COBRA status)