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Gender	Name	Date of Birth (MM/DD/YY)	Zip Code	Coverage	Active/Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra
Select female male				Select EE Employee Only ES Employee Spouse EC Employee Child EF Employee Family	Select Active Cobra