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EMPLOYEE

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CHRIS JOHNSON

ACTIVE 07/01/2012

Demographics

First Name* CHRIS

Middle Initial

Last Name * JOHNSON

Alternate ID 912594310

Social Security # *****6789

Gender * FEMALE

Date of Birth * 05/17/1969

Date of Hire 07/01/2012

Original Effective Date 07/01/2012

Retirement Date

Address & Phone

Country UNITED STATES

Address Line 1 * 2504 MAIN STREET

Address Line 2

City * HARTFORD

State * CT

Zip Code * 06070

Home Phone

DEPENDENT

* Required

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PAT JOHNSON

07/01/2012

Demographics

First Name* PAT

Middle Initial

Last Name * JOHNSON

Social Security #

Relationship * Spouse

Gender * MALE

Date of Birth * 08/01/1972

Original Effective Date * 05/17/1969

Has Cobra Coverage

REBECCA JOHNSON

07/01/2012

Demographics

First Name* REBECCA

Middle Initial

Last Name * JOHNSON

Social Security #

Relationship * Child

Gender * Female

Date of Birth * 10/16/1998

Original Effective Date * 05/17/1969

Has Cobra Coverage

NEW DEPENDENT

07/01/2012

Demographics

First Name *

Middle Initial

Last Name *

Social Security # * SSN Disclaimer

Gender *

Date of Birth *

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Policy # 00N2984 - SPR 400041608 TC 2

Effective Date

EMPLOYEE

Demographics

Address & Phone

DEPENDENT

Demographics

Demographics

Demographics