ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACADAEAFAGAHAIBRBSBT
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3A. PURPLECOW 2025 MASTERLIST (Q1)
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1COMPANY NAMECOMPANY TELEPHONE NUMBERADDRESS
1. Fill in RED CIRCLES to set avlb R&B | MOP
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2CONTACT PERSON | POSITIONCONTACT NUMBEREMAIL ADRESS
2. Fill in member info in YELLOW COLUMNS
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3CEO'S NAME | CEOCONTACT NUMBER<CEO E-MAIL>
3. Click dropdown choices in BLUE COLUMNS
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4INDUSTRYPRINCIPALS00
4. Click on any of the BLUE FONTS for details
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5EFFECTIVE DATE
5. RED CIRCLES should match MED total (W14)
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6INSURED PREMIUM Account >>MODAL PREMIUMMODE OF PAYMENTTOTAL ANNUAL PREMIUMCOST / HEAD6
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700.000 7
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8GH-01234<AGENT>SEC/DTI REG. >>2024080164567-34BIR 2303/TIN >>010-842-092-00008
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Less000Less1GRAND TOTALS000000#DIV/0!0.000.000000.00000000000.0
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 MEMBER MOVEMENT
PERSONAL INFORMATION
STANDARD COVERAGE
OPT. BENEFITS
OPT. TERMS
PREMIUM COSTS
AGE
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#ADDEFF DATELAST NAMESFXFIRST NAMEMISEXBIRTHDAYPRINCIPALSTATUSMISCMOBILEEMAILPOOLMOPRANKR&BMBLMEDDENAPE1-5x L&ABROABLIPHCCOANNUALSEMIQTRMO#
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CHG
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(MM/DD/YY)M/F(MM/DD/YY)DEPENDENTHIERARCHY RULE
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DEL
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10000 10
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20000 20
23
30000 30
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40000 40
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50000 50
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60000 6
27
70000 7
28
80000 8
29
90000 9
30
100000 10
31
110000 11
32
120000 12
33
130000 13
34
140000 14
35
150000 15
36
160000 16
37
170000 17
38
180000 18
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190000 19
40
200000 20
41
210000 21
42
220000 22
43
23 0000 23
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24 0000 24
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25 0000 25
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26 0000 26
47
27 0000 27
48
28 0000 28
49
29 0000 29
50
30 0000 30
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31 0000 31
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32 0000 32
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33 0000 33
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34 0000 34
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35 0000 35
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36 0000 36
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37 0000 37
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38 0000 38
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39 0000 39
60
40 0000 40
61
41 0000 41
62
42 0000 42
63
43 0000 43
64
44 0000 44
65
45 0000 45
66
46 0000 46
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47 0000 47
68
48 0000 48
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49 0000 49
70
50 0000 50
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51 0000 51
72
52 0000 52
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53 0000 53
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54 0000 54
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55 0000 55
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56 0000 56
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57 0000 57
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58 0000 58
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59 0000 59
80
60 0000 60
81
61 0000 61
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62 0000 62
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63 0000 63
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64 0000 64
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65 0000 65
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66 0000 66
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67 0000 67
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68 0000 68
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69 0000 69
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70 0000 70
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71 0000 71
92
72 0000 72
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73 0000 73
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74 0000 74
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75 0000 75
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76 0000 76
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77 0000 77
98
78 0000 78
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79 0000 79
100
80 0000 80
101
81 0000 81