Action Required: Manually add employee, traditional coverage, not late
Customer ID: 0123456
Customer Name: Blankety blank customer
Billing ID: E1821129
Billing Name: Blankety blank customer
Payroll Frequency:
Reason for Enrollment: New Applicant
First Name: New
Middle Initial:
Last Name: Customer
Suffix:
Date of Birth: 99/99/9999
Gender: F
SSN: 123456789
Employee ID:
Date of Hire: 11/10/01
Date Newly Eligible: 11/10/01
Earnings: 100000.00
Earnings Mode: A
Eligibility Class: Blah Blah Blah
Signature Date:
Automatically Enrolled Coverages:
Blankety Blank Coverage1 (Coverage Effective Date 10/28/2010)
Blankety Blank Coverage2 (Coverage Effective Date 10/28/2010)
Blankety Blank Coverage 3 (Coverage Effective Date 10/28/2010)
Blankety Blank Coverage 4 (Coverage Effective Date 10/28/2010)
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