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| Current Location: | Home > Interactive Demonstration > Employer Connection > The NEW Online Enrollment > Online Enrollment Group Change |
April 19, 2024
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| Name | Relationship | Date of Birth | Effective Date | Termination Date |
|---|---|---|---|---|
| STONE, KERWIN J | Employee | 02/17/1975 | 02/01/2007 | |
| STONE, CHARLENE J | Spouse | 02/17/1975 | 02/01/2007 | |
| STONE, LINUS L | Child | 05/21/1983 | 02/01/2007 |
For individual updates, click the specific dependent you wish to maintain.
Select/Deselect All| Select | Name | Relationship | Date of Birth | Effective Date | Termination Date |
|---|---|---|---|---|---|
 | STONE, KERWIN J | Employee | 02/17/1975 | 02/01/2007 | |
| STONE, CHARLENE J | Spouse | 02/17/1975 | 02/01/2007 | |
| STONE, LINUS L | Child | 05/21/1983 | 02/01/2007 |
Please select any dependents that should be changed with the same information as the Employee.
| Current Group: | 20883-000-00000-28011 FULLY INSURED |
| Enter the New Group Number: |   |
| Enter the Effective Date of the Group Change: |  Format: MM/DD/YYYY |
| Hire Date: |  Format: MM/DD/YYYY |
| ENR0007-Eff Date Does not Equal Waiting Period. Enter a Qualifying Event Code. |
| Qualifying Event: |  |
