Employee Detail

Employee Number
12345678
Birthdate
10/05/1985
Social Security
XXX-XX-1234
Date of Hire
01/01/2001
Employee Type
Full-Time
Employment Status
Active
Notification Status
Enrolled
Notes
One cool dude!

Employee Address of Record

Address 1
1234 Coolidge Ave.
Address 2
APT. B12
City
Fontana
State
CA
Zip Code
90201
Telephone
123-456-7890

Doctor Information

Primary Physician
Jane Doe
Address
1286 Anywhere St
City ST Zip
Anaheim, CA 92804
Telephone
714-567-8901
Group
Group Name
Specialty
Brain Surgery

Attachments

Proof of Mail
Proof of Mail
Proof of Mail

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Employee Number
Name Change
Social Security
Date of Hire ( MM/DD/YYYY )
Employee Type
Employment Status
Notification Status
Notes

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Address 1
Address 2
City, ST ZIP
Phone

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Primary Physician
Address
City, ST ZIP
Phone
Group
Specialty

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Description

Date

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04/27/2011
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04/27/2011