Employee code

Enter an employee code.

Name

Select [Self] or the [Dependent Name] you wish to add insurance coverage for.

Insurance code Insurance type

Enter a valid insurance code. The insurance type will default from Insurance Code Maintenance.

Status

Select a status type for the insurance coverage.

Policy number

Enter a policy number, if available.

Effective date

Enter an effective date the insurance coverage begins, if applicable.

Expiration date

Enter an effective date the insurance coverage ends, if applicable.

COBRA amount

If COBRA was selected in Status, enter a COBRA amount here.

Note

Enter any notes for this insurance coverage, if applicable.