| Policy Number: 000001 |
Division Number: 00001 |
  
| Chg/Decl |
Soc Sec Num |
Member Name |
Dep Coverage |
Class |
| change/decline |
111-11-9999 |
Johnson,Marlene R |
Waived |
01 – All eligible members |
| change/decline |
222-11-9999 |
Jones,Karla |
Member Only |
01 – All eligible members |
| change/decline |
555-11-9999 |
Smith,John A |
Member and Family |
01 – All eligible members |
| change/decline |
666-11-9999 |
Carlson, Dan L |
Member and Family |
01 – All eligible members |
* Clicking on the SSN will take you to the Member Enrollment Information screen.
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