FLORIDA HEALTH AGENCY Blank Group HEALTH INSURANCE CENSUS
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Health Insurance Census
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Group name: All Floor Supply LLC Under the File menu select Make a Copy to save to your Google drive or Download As to eport as an Excel Sheet.
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Effective date: 11/01/2018 or 12/01/2018
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Total number of employees: 5Coverage requested codes:
EE - Employee only
EC - Employee and Child(ren)
ES - Employee and Spouse
FF - Full Family
W - Waiving all coverage
L/O - Life only
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Total number of eligible employees: Everyone
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State(s): Boynton Beach, Florida
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Dental? Yes
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Vision? Yes
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Accident? No
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Life coverage: No
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Note: Employees eligible within 60 days of the group's effective date must complete the enrollment process. Do you have a valid EIN?
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LastFirstDate of birthGenderSmokerMarital statusSpouse DOBSpouse Smoker?Number of childrenCoverage requested codeZIPCODEDate of hireAny Pre-existingBusiness location
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HolzbergHoward06/25/1957MaleNoMarried01/02/1969No133414N/aBoynton Beach
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WuJyuing01/02/1969FemaleNoMarried06/25/1957No133414N/aBoynton Beach
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WuPenglin1/2/2000MaleNoSingle33414N/aBoynton Beach
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WadoloswiPaul04/03/1991MaleNoSingle33436N/aBoynton Beach
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CohenAlessandra03/08/1972FemaleNoMarriedN/aN/a033418N/a
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Fully insured plans are administered by Starmark and insured by Trustmark Life Insurance Company.
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Self-funded plans are administered by Starmark, and stop-loss insurance is provided by Trustmark Life Insurance Company, Lake Forest, IL.
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