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Date of Birth Sex Zip Smoker(Y/N) Coverage # of Children               Employee 1 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 2 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 3 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 4 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 5 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 6 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 7 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 8 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 9 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 10 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 11 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 12 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 13 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 14 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 15 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 16 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 17 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 18 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 19 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family Employee 20 Select M F Select Y N Select Self Self + Spouse Self + Children Self + Child Family               * Enter Security Code: