Demo Form GROUP NAME: GROUP EMAIL: GROUP ADDRESS: City: State / Territory Alabama (AL)Alaska (AK)Arizona (AZ)Arkansas (AR)California (CA)Colorado (CO)Connecticut (CT)Delaware (DE)Florida (FL)Georgia (GA)Hawaii (HI)Idaho (ID)Illinois (IL)Indiana (IN)Iowa (IA)Kansas (KS)Kentucky(KY)Louisiana (LA)Maine (ME)Maryland (MD)Massachusetts (MA)Michigan (MI)Minnesota (MN)Mississippi (MS)Missouri (MO)Montana (MT)Nebraska (NE)Nevada (NV)New Hampshire (NH)New Jersey (NJ)New Mexico (NM)New York (NY)North Carolina (NC)North Dakota (ND)Ohio (OH)Oklahoma (OK)Oregon (OR)Pennsylvania (PA)Rhode Island (RI)South Carolina (SC)South Dakota (SD)Tennessee (TN)Texas (TX)Utah (UT)Vermont (VT)Virginia (VA)Washington (WA)West Virginia (WV)Wisconsin (WI)Wyoming (WY)American Samoa (AS)District of Columbia (DC)Federated States of Micronesia (FM)Guam (GU)Marshall Islands (MH)Northern Mariana Islands (MP)Palau (PW)Puerto Rico (PR)Virgin Islands (VI)Armed Forces Africa (AE)Armed Forces Americas (AA)Armed Forces Canada (AE)Armed Forces Europe (AE)Armed Forces Middle East (AE)Armed Forces Pacific (AP) Zip Code: EFFECTIVE DATE: INDUSTRY: REQUESTING AGENCY: Benefits Alliance, LLC NAME/INITIALS GENDER EMPLOYEEDOB/AGE SPOUSEDOB/AGE CHILD 1AGE/DOB CHILD 2AGE/DOB CHILD 3AGE/DOB CHILD 4AGE/DOB TYPE OF COVERAGE LOCATION STATE MaleFemaleOther ---EE = EMPLOYEE ONLYES = EMPLOYEE & SPOUSEEC = EMPLOYEE & CHILDFAM = FAMILYW = WAIVER MaleFemaleOther ---EE = EMPLOYEE ONLYES = EMPLOYEE & SPOUSEEC = EMPLOYEE & CHILDFAM = FAMILYW = WAIVER MaleFemaleOther ---EE = EMPLOYEE ONLYES = EMPLOYEE & SPOUSEEC = EMPLOYEE & CHILDFAM = FAMILYW = WAIVER MaleFemaleOther ---EE = EMPLOYEE ONLYES = EMPLOYEE & SPOUSEEC = EMPLOYEE & CHILDFAM = FAMILYW = WAIVER MaleFemaleOther ---EE = EMPLOYEE ONLYES = EMPLOYEE & SPOUSEEC = EMPLOYEE & CHILDFAM = FAMILYW = WAIVER MaleFemaleOther ---EE = EMPLOYEE ONLYES = EMPLOYEE & SPOUSEEC = EMPLOYEE & CHILDFAM = FAMILYW = WAIVER MaleFemaleOther ---EE = EMPLOYEE ONLYES = EMPLOYEE & SPOUSEEC = EMPLOYEE & CHILDFAM = FAMILYW = WAIVER MaleFemaleOther ---EE = EMPLOYEE ONLYES = EMPLOYEE & SPOUSEEC = EMPLOYEE & CHILDFAM = FAMILYW = WAIVER MaleFemaleOther ---EE = EMPLOYEE ONLYES = EMPLOYEE & SPOUSEEC = EMPLOYEE & CHILDFAM = FAMILYW = WAIVER MaleFemaleOther ---EE = EMPLOYEE ONLYES = EMPLOYEE & SPOUSEEC = EMPLOYEE & CHILDFAM = FAMILYW = WAIVER Δ
