EMPLOYEE CENSUS PAGE


 
Employee Information

Employee Name

Employee SSN

Employee Gender

Employee Date of Birth
POST, MARK M

 111111111

 M

 02/30/1967
Group Name Unit Name
PROFESSIONAL STAFF MANAGEMENT, INC

 FUTURE VISION LAND
Current Home Address City State Zip
1234 AVENUE ROAD #12

 APPLETON

 UT

 82216


Employee Enrollment Information    
Medical Dental Vision
Beg Date End Date Plan Option Coverage
10/01/199709/30/1998PSMI001PLATINUMTwo-Party
01/01/2001 PSMI001TITANIUMFamily
Beg Date End Date Plan Option Coverage
Beg Date End Date Plan Option Coverage
 


Family Members Enrollment Information
Last Name First Name MI Sex Birthdate Rel Coverage Beg Coverage End Student Disabled Other Insurance Notes
POSTSUSANB F04/16/1970SPO 01/01/2002 N NN 
POSTDEFASA M12/31/2001SON 01/01/2002 N NN 


Benefits Accumulators (Deductibles, Limits, etc.)
Patient Name Accumulator Calendar Year 2003 Calendar Year 2004
FamilyAnnl In-Network Ded (Medical) 500.00 0.00
FamilyAnnl In-Network OOP (Medical) 53.94 0.00
FamilyAnnl Out-of-Network Ded (Medical) 500.00 0.00
FamilyAnnl Out-of-Network OOP (Medical) 315.46 0.00
EmployeeAnnl Preventative (Medical) 123.76 0.00
EmployeeAnnl In-Network Ded (Medical) 0.00 0.00
EmployeeAnnl In-Network OOP (Medical) 0.00 0.00
EmployeeLifetime General Dollar (Medical) 0.00 919.60
EmployeeAnnl Out-of-Network Ded (Medical) 0.00 0.00
EmployeeAnnl Out-of-Network OOP (Medical) 0.00 0.00
SUSAN POSTAnnl Psych Days (Medical)0 0
SUSAN POSTAnnl In-Network Ded (Medical) 0.00 0.00
SUSAN POSTAnnl In-Network OOP (Medical) 0.00 0.00
SUSAN POSTLifetime General Dollar (Medical) 0.00 3664.57
SUSAN POSTAnnl Out-of-Network Ded (Medical) 0.00 0.00
SUSAN POSTAnnl Out-of-Network OOP (Medical) 0.00 0.00
DEFAS A. POSTAnnl Preventative (Medical) 76.56 0.00
DEFAS A. POSTAnnl Psych Dollar (Medical) 736.07 0.00
DEFAS A. POSTAnnl Psych Visits (Medical)0 0
DEFAS A. POSTAnnl In-Network Ded (Medical) 500.00 0.00
DEFAS A. POSTAnnl In-Network OOP (Medical) 53.94 0.00
DEFAS A. POSTLifetime General Dollar (Medical) 0.00 7024.05
DEFAS A. POSTAnnl Out-of-Network Ded (Medical) 500.00 0.00
DEFAS A. POSTAnnl Out-of-Network OOP (Medical) 315.46 0.00