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COBRA/Direct Bill Administration  >  Plan Details

Plan Details  
Client:  ABC BUILDERS, INC.
Demographics
Important Information Name/Address
Event Date: 01/01/2006
Notified: 01/01/2006
Elected: 01/01/2006
Election Received: 01/01/2006
Event Type: INDIVIDUAL CONVERSION
Status: Enrolled
Class: 0
Salary: 0
Years of Service: 0
Sponsor Date: 01/01/2006
PAT SMITH
123 MAIN ST
ANYTOWN
WI 55555

Phone:  555 555 1212
Email: 
Birth Date:  11/12/1957
Gender:  F
Marital:  Married

Coverages/Elections
Carrier Name Tier Description Premium Effective Eligibility Ends Paid Thru Date
Health 123 Plan Individual + Children
01/01/2006 09/30/2009

Payments
  Coverage Bill Amt. Due Date Balance
Health 123 Plan
Starting: 10/01/2009
$290.83
Due: 10/01/2009
$290.83
Health 123 Plan
Starting: 09/01/2009
$390.83
Due: 09/01/2009
$100.00
Health 123 Plan
Starting: 08/01/2009
$490.83
Due: 08/01/2009
$100.00
Total Balance: $290.83

Dependents
First Name Last Name Relationship Birth Date Effective
Jack Smith Son 04/14/1997 01/01/2006
Susan Smith Daughter 02/21/1999 01/01/2006

Other Information
IDDescriptionValue
HIREDTEEmployment Date 01/01/2006
RETDTERetirement Date 
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