ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACADAEAFAGAHAIAJAKALAMANAOAP
1
Make a copy of this template. Review Hints/Tips. Remove all example rows and instructions before submitting. Items in red are required! (Items in orange may be required)
2
Hints/Tips >>>
3
RequiredRequired only if billing groups are utilizedRequired
Employee SSN must be in all dependent rows.
9-digit number.
If no SSN a ITIN can be used.

Pro Tip: If using Excel, set this column to Plain Text to keep leading zeros.		Required for the Employee.
*If dependent SSN is not available, please leave the field for Member SSN blank.
*If dependent is also an employee AND the group offers employer paid life coverage, DO NOT include dependent SSN.
*If someone is both an employee and a dependent, only include their SSN in the rows where their member role is Employee.
9-digit number.

Pro Tip: If using Excel, set this column to Plain Text to keep leading zeros.		Required
List of acceptable roles:
Subscriber
EMPLOYEE SPOUSE CHILD		Required
Not Required
Can also be full middle name. Alphabetic characters only, do NOT use punctuation.
"A" or "Ann" not "A."		Required
Not RequiredNot RequiredRequired
Female or F
Male or M
Other or O		Required
MM/DD/YYYY		Required for the Employee

Email is used for EOI, Beam member portal and Perks program registration.

Employee can register online or on the Beam App for Perks		Not Required
Ten-digit number with or without dashes		Not Required
Ten-digit number with or without dashes		Required Required only if
applicable
Suite/Floor/Unit etc		Required Required
Two character state abbreviation.		Required
Five or nine-digit postal code

Pro Tip: If using Excel, set this column to Plain Text to keep leading zeros.		Not Required

Highly recommended for Voluntary Supplemental Life and Critical Illness to improve a member’s EOI experience 		Required only for
disabled dependents
over the age of 26

Yes
No		Not Required

Yes
No		Not Required

Highly recommended for Voluntary Supplemental Life and Critical Illness to improve a member’s EOI experience 		Required
MM/DD/YYYY		Required if terminating employment.
MM/DD/YYYY		Required if previously employed
MM/DD/YYYY

A rehire scenario occurs when an employee who has previously terminated coverage is rehired and resumes coverage with a gap between the employment end date and the provided Policy Start Date. 		Required for wage based lines of coverage
Formatted to two decimal places dollars.cents (EX 15.23) and no special characters ($ or ¢)

The subscribers wage tied to wage frequency (--->)		Required for wage based lines of coverage

Hourly
Weekly
Annually

The frequency tied to the wage (<---)		Required
Type in 40		Required for wage based lines of coverage
MM/DD/YYYY		Required - one line per line of coverage selected.

Valid Coverage Types are:
Dental
Vision
Basic Life
Required - name must match plan exactly

Ex: SmartPremium Plus 100/80/50/50-2000 MAC		Required
MM/DD/YYYY		Required for Termination of a Line of Coverage
MM/DD/YYYY		Required only for
rollover dental plans
Can only be submitted on the initial census		Required only for
rollover dental plans
Can only be submitted on the initial census		Required for Voluntary Supplemental Life

Numeric values only - no $ or ,		Not Required

Can only be provided only after completion of EOI and if a value is provided, it MUST match the Beam system		Required for Termination of Coverage due to termination of employment

MM/DD/YYYY		Required only if
outside of open
enrollment

MM/DD/YYYY		Required only if
outside of open
enrollment

MM/DD/YYYY
4
Group NumberBilling GroupEmployee SSNMember SSNMember Role
Member First Name
Member Middle Initial
Member Last NameName PrefixName SuffixMember GenderMember Date of BirthSubscriber EmailSubscriber Home PhoneSubscriber Cell PhoneAddress 1Address 2CityStateZipStudent StatusHandicap StatusTobacco UseSubscriber Job TitleSubscriber Date of Hire
Employment End Date
Rehire Date Wage Wage FrequencyWage Hours
Wage Effective Date
Coverage TypePolicy NamePolicy Start DatePolicy End DateCoinsurance RolloverDeductible RolloverRequested Coverage AmountApproved Coverage Amount
Certificate Termination Date
ReasonEvent Date
5
OH00001777-88-9999777-88-9999EmployeeJohnWilliamsMale3/10/1980john.williams@noemail.com629 N High StColumbusOH432151/1/201040DentalSmartPremium Plus 100/80/50/50-2000 MAC1/1/2023
6
OH00001777-88-9999777-88-9999EmployeeJohnWilliamsMale3/10/1980john.williams@noemail.com629 N High StColumbusOH432151/1/201040VisionVSP Choice Plan #31/1/2023
7
OH00001777-88-9999777-88-9999EmployeeJohnWilliamsMale3/10/1980john.williams@noemail.com629 N High StColumbusOH432151/1/201040Basic Life25k Shelf-Rated Life1/1/2023
8
Group NumberBilling GroupEmployee SSNMember SSNMember Role
Member First Name
Member Middle Initial
Member Last NameName PrefixName SuffixMember GenderMember Date of BirthSubscriber EmailSubscriber Home PhoneSubscriber Cell PhoneAddress 1Address 2CityStateZipStudent StatusHandicap StatusTobacco UseSubscriber Job TitleSubscriber Date of Hire
Employment End Date
Rehire Date Wage Wage FrequencyWage Hours
Wage Effective Date
Coverage TypePolicy NamePolicy Start DatePolicy End DateCoinsurance RolloverDeductible RolloverRequested Coverage AmountApproved Coverage Amount
Certificate Termination Date
ReasonEvent Date
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100