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11 Cell Phone Number Cellphone number for member <br /> Do not add Country Code <br /> 12 Insurance Carrier and Plan Name of the insurance carrier and plan name <br /> Name Example: Aetna PPO <br /> 13 Insurance Group/Plan Insurance group or plan number <br /> Number Example: 16578-86565-876543 <br /> 14 Individual Insurance ID The identification number for the member <br /> Number (employee, spouse/domestic partner or child) <br /> Example: KL 568769 <br /> 15 Occupation For employees only - occupation/job role <br /> Example: Accounting Specialist <br /> 16 Department Name For employees only -name of department and <br /> location <br /> Example: Marketing, Seattle <br /> 17 Employee ID Employee ID <br /> Example: 34464 <br /> 18 Hire Date Date (MM/DD/YYYY) employee was hired. <br /> This is REQUIRED information when <br /> someone is newly hired. <br /> 19 Insurance Eligibility Date Date (MM/DD/YYYY)that the member <br /> (employee, spouse/domestic partner or child) <br /> is eligible for insurance <br /> 20 Term Date Date (MM/DD/YYYY) an employee was <br /> terminated, if applicable. This is REQUIRED <br /> information when an employee is terminated. <br /> Retain the details of the terminated employee <br /> the month following termination also. In <br /> subsequent months the member should not be <br /> included. <br /> Example: if an employee was terminated on <br /> 07/06/2018,then 07/06/2018 should be listed <br /> in this column for August and not included <br /> thereafter. <br /> 21 Insurance Coverage End Date (MM/DD/YYYY)that the insurance <br /> Date coverage of the member(employee, <br /> spouse/domestic partner or child) ends, if <br /> applicable <br /> 22 Marital State.s Marital status of the member <br /> See Table 1 for values <br /> 23 Date of Birth Date of birth(MM/DD/YYYY) of the <br /> member <br /> Exhibit 1, Page 3 <br />