SSO Enrollment Integration----------- RoleID-> 3 UserID-> 5187 LoggedUserName-> Aditya Vishwakarma EmployeeID-> 103 EmpID-> Function Name-- > ProcessSuccessSAMLResponse Custom Message--> SelerixSSOModel --> ProcessSuccessSAMLResponse -->Transmittal enveloap received from Selerix : University Health System 2018 UHS_2018 Web Self-Service
8037444825 edi@selerix.com Web Self-Service 0 Unknown Chubb Critical Illness CIC_GCI Chubb Lifetime Benefit Term CIC_LBT Chubb Accident CIC_ACC Chubb Critical Illness CIC_GCI Chubb Lifetime Benefit Term CIC_LBT Chubb Accident Diamond CIC_ACC Chubb Accident Gold CIC_ACC CIC_114159_Occupation CIC_114159_Actively_at_Work #bodyContent_MainCtrl_PersonDIP_STD_EMPLOYED_THIRTY_b6e5be1a-dc00-44e3-b8ad-1ff269d1eec9 { width: 825px; height: 80px; } #contentContent { clear:both; } #bodyContent_MainCtrl { } #bodyContent_MainCtrl_MainCtrl_table { } .questionCtrl-global{ margin-top: 2px; padding:2px; background:#f5f5f5; border:1px solid #ddd; overflow:auto; } .questionCtrl-row { padding:5px; overflow:hidden; } *{ box-sizing: border-box; } .questionCtrl-global > .questionCtrl-parent, .questionCtrl-global > ..questionCtrl-sub { float: left; width: 65%; } .questionCtrl-global > .questionCtrl-answer, .questionCtrl-global > .questionCtrl-answer-under { float: right; width: 33%; text-align: left; } div { display: block; } .lead { margin-top: 0px; }
Are you actively at work at least <%=Event.Engine.Properties["min_hours_per_week"]; %> hours each week?
]]> CIC_114159_Authorization_Language
<% switch (Event.EnrollmentState) { case 'DE': %>

It is very important that you review your enrollment form very carefully. Misstatements or omissions could cause an otherwise valid claim to be denied. The effective date of approved coverage will be determined as set forth in the certificate of coverage provided to me. I understand that any insurance applied for will not take effect unless and until Combined Insurance Company of America approves my application. If coverage cannot be issued as applied for under the rules of the Company, I authorize Combined Insurance Company of America to issue reduced benefits and adjust premiums to match the coverage issued. I authorize my employer to deduct the premiums for this insurance from my earnings ( unless the coverage for which I am applying allows for alternate methods to pay insurance premiums).

In applying for this coverage, I represent and affirm that the information which I have given as recorded on the Application is true and complete to the best of my knowledge and belief. No person listed on this enrollment form is covered by Medicaid.
<% break; case 'MN': %>

It is very important that you review your enrollment form very carefully. Misstatements or omissions could cause an otherwise valid claim to be denied. The effective date of approved coverage will be determined as set forth in the certificate of coverage provided to me. I understand that any insurance applied for will not take effect unless and until Combined insurance Company of America approves my application. If coverage cannot be issued as applied for under the rules of the Company, I authorize Combined Insurance Company of America to issue reduced benefits and adjust premiums to match the coverage issued. I authorize my employer to deduct the premiums for this insurance from my earnings (unless the coverage for which I am applying allows for alternate methods to pay insurance premiums).

In applying for this coverage, I represent and affirm that the information which I have given as recorded on this Enrollment Form is true and complete to the best of my knowledge and belief.
<% break; case 'MT': %>

It is very important that you review your enrollment form very carefully. Misstatements or omissions could cause an otherwise valid claim to be denied. The effective date of approved coverage will be determined as set forth in the certificate of coverage provided to me. I understand that any insurance applied for will not take effect unless and until Combined insurance Company of America approves my application. If coverage cannot be issued as applied for under the rules of the Company, I authorize Combined Insurance Company of America to issue reduced benefits and adjust premiums to match the coverage issued. I authorize my employer to deduct the premiums for this insurance from my earnings (unless the coverage for which I am applying allows for alternate methods to pay insurance premiums).

In applying for this coverage, I represent and affirm that the information which I have given as recorded on this Enrollment Form is true and complete to the best of my knowledge and belief.
<% break; case 'NH': %>

It is very important that you review your enrollment form carefully. Misstatements or omissions could cause an otherwise valid claim to be denied. The effective date of approved coverage will be determined as set forth in the certificate of coverage provided to me. I understand that any insurance applied for will not take effect unless and until Combined Insurance Company of America approves my application. If coverage cannot be issued as applied for under the rules of the Company, I authorize Combined Insurance Company of America to issue reduced benefits and adjust premiums to match the coverage issued. I authorize my employer to deduct the premiums for this insurance from my earnings (unless coverage for which I am applying allows for alternate methods to pay insurance premiums).

In applying for this coverage, I represent and affirm that the information which I have given as recorded on this Enrollment Form is true and complete to the best of my knowledge and belief.
<% break; default: %>

It is very important that you review your enrollment form carefully. Misstatements or omissions could cause an other wise valid claim to be denied. The effective date of approved coverage will be determined as set forth in the certificate of coverage provided to me. I understand that any insurance applied for will not take effect unless and until Combined Insurance Company of America approves my application. If coverage cannot be issued as applied for under the rules of the Company, I authorize Combined Insurance Company of America to issue reduced benefits and adjust premiums to match the coverage issued. I authorize my employer to deduct the premiums for this insurance from my earnings (unless coverage for which I am applying allows for alternate methods to pay insurance premiums).

In applying for this coverage, I represent and affirm that the information which I have given as recorded on this Enrollment Form is true and complete to the best of my knowledge and belief.

<% break; } %>]]> CIC_114159_Fraud_Language

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines and denial of insurance benefits.
<% break; case 'AL': %>

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.
<% break; case 'AR': %>

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
<% break; case 'CA': %>

The falsity of any statement in the application for any policy shall not bar the right to recovery under the policy unless such false statement was made with actual intent to deceive or unless it materially affected either the acceptance of risk or the hazard assumed by Combined.
<% break; case 'CO': %>

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
<% break; case 'DC': %>

WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
<% break; case 'FL': %>

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
<% break; case 'KS': %>

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto may be guilty of insurance fraud as determined by a court of law.
<% break; case 'KY': %>

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
<% break; case 'LA': %>

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
<% break; case 'MD': %>

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
<% break; case 'NH': %>

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties.
<% break; case 'NJ': %>

Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
<% break; case 'NM': %>

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties..
<% break; case 'OH': %>

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
<% break; case 'OK': %>

WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, imcomplete or misleading information is guilty of a felony.
<% break; case 'OR': %>

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
<% break; case 'RI': %>

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
<% break; case 'TN': %>

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines and denial of insurance benefits.
<% break; case 'VA': %>

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines and denial of insurance benefits..
<% break; default: %>

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such aperson to criminal and civil penalties.
<% break; } %>]]> 2017-11-13T12:19:12
USA 5610 Buncombe Rd Apt 608 Shreveport LA 71129
(318) 779-2354 Test1@Test.com 439-39-7071 Chataignier Boult Female University Health System 2016-10-10T00:00:00 2018-01-01T00:00:00 <Department>90</Department> <Location>BRFHH</Location> <JobClass>University Health</JobClass> <PayGroup>Bi-Weekly</PayGroup> <PayrollFrequency>26</PayrollFrequency> <DeductionFrequency>26</DeductionFrequency> <Salary>24960.0000</Salary> <HourlyWage>0.0000</HourlyWage> <FTERate>0.0000</FTERate> <HoursPerWeek>40</HoursPerWeek> <PTOBalance>0.0000</PTOBalance> <PTOCost>0.0000</PTOCost> <FederalTax>0</FederalTax> <FederalUnemploymentTax>0</FederalUnemploymentTax> <StateUnemploymentTax>0</StateUnemploymentTax> <SocialSecurityTax>0</SocialSecurityTax> <MedicareTax>0</MedicareTax> <WorkersComp>0</WorkersComp> <Bonus>0</Bonus> <Commissions>0</Commissions> <Overtime>0</Overtime> <StockOptionGrantValue>0</StockOptionGrantValue> </Employment> <LegalStatus>Employee</LegalStatus> <Relationship>Employee</Relationship> <BirthDate>1975-04-09T00:00:00</BirthDate> <SmokerStatus>Never</SmokerStatus> <Student>false</Student> <Disabled>false</Disabled> <EmployeeIdent>103</EmployeeIdent> <PIN>26800</PIN> <EnrollmentSession Status="Complete"> <Location>BRFHH</Location> <City>Shreveport</City> <State>LA</State> <EnrollerID>Web Self Service</EnrollerID> <EnrollerAssisted>false</EnrollerAssisted> <EnrollmentType>Unknown</EnrollmentType> <LastStatusUpdate>2017-11-10T19:37:01</LastStatusUpdate> <Offerings /> <Journal /> </EnrollmentSession> <PaymentInfo> <PaymentType>Payroll</PaymentType> <BankDraftDay>0</BankDraftDay> </PaymentInfo> <Questionnaire> <Answer QuestionID="CIC_114159_Occupation"> <Name>CIC_114159_Occupation</Name> <Value>Patient Access Representative</Value> </Answer> <Answer QuestionID="CIC_114159_Actively_at_Work"> <Name>CIC_114159_Actively_at_Work</Name> <Value>True</Value> </Answer> <Answer QuestionID="CIC_114159_Authorization_Language"> <Name>CIC_114159_Authorization_Language</Name> <Value>True</Value> </Answer> <Answer QuestionID="CIC_114159_Fraud_Language"> <Name>CIC_114159_Fraud_Language</Name> <Value>True</Value> </Answer> </Questionnaire> </Applicant> <Applicant ID="c47bda77-6e8f-43ff-b8c3-61d389f2e8c3" UniqueID="c47bda77-6e8f-43ff-b8c3-61d389f2e8c3" DependentNumber="1" EmployeeID="7448e507-09c4-4574-8011-354860e11fdf"> <AsOfDate>2017-11-13T12:19:09</AsOfDate> <Address Type="Personal"> <Country>USA</Country> <Line1>5610 Buncombe Rd</Line1> <Line2>Apt 608</Line2> <City>Shreveport</City> <State>LA</State> <Zip>71129</Zip> </Address> <SSN /> <FirstName>Brandon</FirstName> <MiddleInitial /> <LastName>Davis</LastName> <Sex>Male</Sex> <LegalStatus>Child</LegalStatus> <Relationship>Child</Relationship> <BirthDate>1997-06-27T00:00:00</BirthDate> <SmokerStatus>Never</SmokerStatus> <Student>false</Student> <Disabled>false</Disabled> <Questionnaire> <Answer QuestionID="CIC_114159_Occupation"> <Name>CIC_114159_Occupation</Name> <Value>Patient Access Representative</Value> </Answer> <Answer QuestionID="CIC_114159_Actively_at_Work"> <Name>CIC_114159_Actively_at_Work</Name> <Value>True</Value> </Answer> <Answer QuestionID="CIC_114159_Authorization_Language"> <Name>CIC_114159_Authorization_Language</Name> <Value>True</Value> </Answer> <Answer QuestionID="CIC_114159_Fraud_Language"> <Name>CIC_114159_Fraud_Language</Name> <Value>True</Value> </Answer> </Questionnaire> </Applicant> <Applicant ID="bd00033b-1e50-4e10-b6c7-0b148150c834" UniqueID="bd00033b-1e50-4e10-b6c7-0b148150c834" DependentNumber="2" EmployeeID="7448e507-09c4-4574-8011-354860e11fdf"> <AsOfDate>2017-11-10T22:02:29</AsOfDate> <Address Type="Personal"> <Country>USA</Country> <Line1>5610 Buncombe Rd</Line1> <Line2>Apt 608</Line2> <City>Shreveport</City> <State>LA</State> <Zip>71129</Zip> </Address> <SSN /> <FirstName>D'anna</FirstName> <MiddleInitial /> <LastName>Davis</LastName> <Sex>Female</Sex> <LegalStatus>Child</LegalStatus> <Relationship>Child</Relationship> <BirthDate>1999-04-12T00:00:00</BirthDate> <SmokerStatus>Never</SmokerStatus> <Student>false</Student> <Disabled>false</Disabled> <Questionnaire> <Answer QuestionID="CIC_114159_Occupation"> <Name>CIC_114159_Occupation</Name> <Value>Patient Access Representative</Value> </Answer> <Answer QuestionID="CIC_114159_Actively_at_Work"> <Name>CIC_114159_Actively_at_Work</Name> <Value>True</Value> </Answer> <Answer QuestionID="CIC_114159_Authorization_Language"> <Name>CIC_114159_Authorization_Language</Name> <Value>True</Value> </Answer> <Answer QuestionID="CIC_114159_Fraud_Language"> <Name>CIC_114159_Fraud_Language</Name> <Value>True</Value> </Answer> </Questionnaire> </Applicant> <Applicant ID="6b4b96da-c90e-4977-bb09-9e04981f11cf" UniqueID="6b4b96da-c90e-4977-bb09-9e04981f11cf" EmployeeID="7448e507-09c4-4574-8011-354860e11fdf"> <AsOfDate>2017-11-10T19:36:34</AsOfDate> <Address Type="Personal"> <Country>USA</Country> <Line1>5610 Buncombe Rd</Line1> <Line2>Apt 608</Line2> <City>Shreveport</City> <State>LA</State> <Zip>71129</Zip> </Address> <SSN /> <FirstName>Zachary </FirstName> <MiddleInitial /> <LastName>Davis</LastName> <Suffix /> <Sex>Male</Sex> <LegalStatus>Child</LegalStatus> <LegalStatusDescription /> <Relationship>Child</Relationship> <BirthDate>2003-06-20T00:00:00</BirthDate> <SmokerStatus>Never</SmokerStatus> <Student>false</Student> <Disabled>false</Disabled> <Questionnaire> <Answer QuestionID="CIC_114159_Occupation"> <Name>CIC_114159_Occupation</Name> <Value>Patient Access Representative</Value> </Answer> <Answer QuestionID="CIC_114159_Actively_at_Work"> <Name>CIC_114159_Actively_at_Work</Name> <Value>True</Value> </Answer> <Answer QuestionID="CIC_114159_Authorization_Language"> <Name>CIC_114159_Authorization_Language</Name> <Value>True</Value> </Answer> <Answer QuestionID="CIC_114159_Fraud_Language"> <Name>CIC_114159_Fraud_Language</Name> <Value>True</Value> </Answer> </Questionnaire> </Applicant> <Applicant ID="a18c6332-376f-48fd-a2d2-63ae4c9a3100" UniqueID="a18c6332-376f-48fd-a2d2-63ae4c9a3100" DependentNumber="3" EmployeeID="7448e507-09c4-4574-8011-354860e11fdf"> <AsOfDate>2017-11-13T12:19:09</AsOfDate> <Address Type="Personal"> <Country>USA</Country> <Line1>5610 Buncombe Rd</Line1> <Line2>Apt 608</Line2> <City>Shreveport</City> <State>LA</State> <Zip>71129</Zip> </Address> <SSN /> <FirstName>Zachary</FirstName> <MiddleInitial /> <LastName>Davis</LastName> <Sex>Male</Sex> <LegalStatus>Child</LegalStatus> <Relationship>Child</Relationship> <BirthDate>2003-06-20T00:00:00</BirthDate> <SmokerStatus>Never</SmokerStatus> <Student>false</Student> <Disabled>false</Disabled> <Questionnaire> <Answer QuestionID="CIC_114159_Occupation"> <Name>CIC_114159_Occupation</Name> <Value>Patient Access Representative</Value> </Answer> <Answer QuestionID="CIC_114159_Actively_at_Work"> <Name>CIC_114159_Actively_at_Work</Name> <Value>True</Value> </Answer> <Answer QuestionID="CIC_114159_Authorization_Language"> <Name>CIC_114159_Authorization_Language</Name> <Value>True</Value> </Answer> <Answer QuestionID="CIC_114159_Fraud_Language"> <Name>CIC_114159_Fraud_Language</Name> <Value>True</Value> </Answer> </Questionnaire> </Applicant> <Applicant ID="9b03c9d3-3dd5-4861-b7e3-75d3eca6aaab" UniqueID="9b03c9d3-3dd5-4861-b7e3-75d3eca6aaab" DependentNumber="2" EmployeeID="7448e507-09c4-4574-8011-354860e11fdf"> <AsOfDate>2017-11-13T12:19:09</AsOfDate> <Address Type="Personal"> <Country>USA</Country> <Line1>5610 Buncombe Rd</Line1> <Line2>Apt 608</Line2> <City>Shreveport</City> <State>LA</State> <Zip>71129</Zip> </Address> <SSN /> <FirstName>Danna</FirstName> <MiddleInitial /> <LastName>Davis</LastName> <Sex>Female</Sex> <LegalStatus>Child</LegalStatus> <Relationship>Child</Relationship> <BirthDate>1999-04-12T00:00:00</BirthDate> <SmokerStatus>Never</SmokerStatus> <Student>false</Student> <Disabled>false</Disabled> <Questionnaire> <Answer QuestionID="CIC_114159_Occupation"> <Name>CIC_114159_Occupation</Name> <Value>Patient Access Representative</Value> </Answer> <Answer QuestionID="CIC_114159_Actively_at_Work"> <Name>CIC_114159_Actively_at_Work</Name> <Value>True</Value> </Answer> <Answer QuestionID="CIC_114159_Authorization_Language"> <Name>CIC_114159_Authorization_Language</Name> <Value>True</Value> </Answer> <Answer QuestionID="CIC_114159_Fraud_Language"> <Name>CIC_114159_Fraud_Language</Name> <Value>True</Value> </Answer> </Questionnaire> </Applicant> </Applicants> <Applications> <Application ID="c812e24e-2eab-4ba7-ad4a-37d2918e194e" UniqueID="c812e24e-2eab-4ba7-ad4a-37d2918e194e" EmployeeID="7448e507-09c4-4574-8011-354860e11fdf" ApplicantID="7448e507-09c4-4574-8011-354860e11fdf" Waived="true" ShowErrorMessages="false" Status="Complete"> <AsOfDate>2017-11-10T19:33:36</AsOfDate> <OfferingID>18324</OfferingID> <Coverage> <Tier>No Coverage</Tier> <DeductionFrequency>26</DeductionFrequency> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <BenefitAmountFrequency>0</BenefitAmountFrequency> <Section125>false</Section125> <AllowSection125Change>false</AllowSection125Change> <EffectiveDate>2017-10-26T00:00:00</EffectiveDate> <TerminationDate>2017-10-25T00:00:00</TerminationDate> <FirstDeductionDate>2017-10-26T00:00:00</FirstDeductionDate> </Coverage> <Insureds> <Insured Age="42" ApplicantID="7448e507-09c4-4574-8011-354860e11fdf" /> </Insureds> <Enrollers> <Enroller AgentID="3499"> <Split>100</Split> </Enroller> </Enrollers> <ApplicationDate>2017-11-10T00:00:00</ApplicationDate> <Events /> <PolicyNumber /> </Application> <Application ID="41a4006c-68a8-492f-91b2-011db3fd521f" UniqueID="41a4006c-68a8-492f-91b2-011db3fd521f" EmployeeID="7448e507-09c4-4574-8011-354860e11fdf" ApplicantID="7448e507-09c4-4574-8011-354860e11fdf" Waived="true" ShowErrorMessages="false" Status="Complete"> <AsOfDate>2017-11-10T19:33:36</AsOfDate> <OfferingID>18273</OfferingID> <Coverage> <Tier>No Coverage</Tier> <DeductionFrequency>26</DeductionFrequency> <EmployeeCost>0.0000</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>0.0000</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <BenefitAmountFrequency>0</BenefitAmountFrequency> <Section125>false</Section125> <AllowSection125Change>false</AllowSection125Change> <EffectiveDate>2017-10-26T00:00:00</EffectiveDate> <TerminationDate>2017-10-25T00:00:00</TerminationDate> <FirstDeductionDate>2017-10-26T00:00:00</FirstDeductionDate> </Coverage> <Insureds> <Insured Age="42" ApplicantID="7448e507-09c4-4574-8011-354860e11fdf" /> </Insureds> <Enrollers> <Enroller AgentID="3499"> <Split>100</Split> </Enroller> </Enrollers> <ApplicationDate>2017-11-10T00:00:00</ApplicationDate> <Events /> <PolicyNumber /> </Application> <Application ID="1d4584fa-2d09-4e13-8a71-ffafa442be86" UniqueID="1d4584fa-2d09-4e13-8a71-ffafa442be86" EmployeeID="7448e507-09c4-4574-8011-354860e11fdf" ApplicantID="7448e507-09c4-4574-8011-354860e11fdf" IncreaseEffectiveImmediate="false" ShowErrorMessages="false" Status="Complete"> <AsOfDate>2017-11-10T22:48:49</AsOfDate> <OfferingID>18325</OfferingID> <Coverage ProductID="13887"> <Tier>Employee + Children</Tier> <DeductionFrequency>26</DeductionFrequency> <EmployeeCost>8.3200</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>8.3200</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <BenefitAmountFrequency>0</BenefitAmountFrequency> <OptionCode /> <Description>Chubb Accident Gold; EC</Description> <Section125>false</Section125> <InitialEffectiveDate>2017-10-26T00:00:00</InitialEffectiveDate> <EffectiveDate>2018-01-01T00:00:00</EffectiveDate> <PlanYearStartDate>2017-12-01T00:00:00</PlanYearStartDate> <FirstDeductionDate>2018-01-01T00:00:00</FirstDeductionDate> <EmployerFee>0.0000</EmployerFee> <EmployeeFee>0.0000</EmployeeFee> </Coverage> <PreviousCoverage ProductID="13887"> <Tier>Employee + Children</Tier> <DeductionFrequency>26</DeductionFrequency> <EmployeeCost>8.3200</EmployeeCost> <PreTaxEmployeeCost>0.0000</PreTaxEmployeeCost> <PostTaxEmployeeCost>8.3200</PostTaxEmployeeCost> <EmployerCost>0.0000</EmployerCost> <BenefitAmountFrequency>0</BenefitAmountFrequency> <OptionCode /> <Section125>false</Section125> <InitialEffectiveDate>2017-10-26T00:00:00</InitialEffectiveDate> <EffectiveDate>2017-11-10T00:00:00</EffectiveDate> <TerminationDate>2017-12-31T00:00:00</TerminationDate> <PlanYearStartDate>2016-12-01T00:00:00</PlanYearStartDate> <FirstDeductionDate>2017-11-10T00:00:00</FirstDeductionDate> <LastDeductionDate>2018-01-01T00:00:00</LastDeductionDate> <EmployerFee>0.0000</EmployerFee> <EmployeeFee>0.0000</EmployeeFee> </PreviousCoverage> <Insureds> <Insured Age="42" ApplicantID="7448e507-09c4-4574-8011-354860e11fdf"> <PCPName /> <PCPNumber /> <OtherInsurance /> </Insured> <Insured Age="20" ApplicantID="c47bda77-6e8f-43ff-b8c3-61d389f2e8c3"> <PCPName /> <PCPNumber /> <OtherInsurance /> </Insured> <Insured Age="18" ApplicantID="bd00033b-1e50-4e10-b6c7-0b148150c834"> <PCPName /> <PCPNumber /> <OtherInsurance /> </Insured> <Insured Age="14" ApplicantID="6b4b96da-c90e-4977-bb09-9e04981f11cf"> <PCPName /> <PCPNumber /> <OtherInsurance /> </Insured> <Insured Age="14" ApplicantID="a18c6332-376f-48fd-a2d2-63ae4c9a3100"> <PCPName /> <PCPNumber /> <OtherInsurance /> </Insured> <Insured Age="18" ApplicantID="9b03c9d3-3dd5-4861-b7e3-75d3eca6aaab"> <PCPName /> <PCPNumber /> <OtherInsurance /> </Insured> </Insureds> <Beneficiaries> <Beneficiary UniqueID="00000000-0000-0000-0000-000000000000"> <Type>Primary</Type> <Name>All Living Children</Name> <Phone /> <BeneficiaryAddress> <FullAddress /> </BeneficiaryAddress> <Percent>100.0000</Percent> <FirstName /> <LastName /> <SSN /> <RelationshipDescription /> <CountryOfCitizenship /> </Beneficiary> </Beneficiaries> <Enrollers> <Enroller AgentID="3499"> <Number /> <Split>100</Split> </Enroller> </Enrollers> <ApplicationDate>2017-11-10T16:48:49</ApplicationDate> <Events> <Event EventClass="Changed"> <UserID>3499</UserID> <EventDate>2017-11-10T22:48:49</EventDate> <ReasonCode>1</ReasonCode> <Reason>[dependent added] </Reason> <EventDetails> <EventDetail EventClass="Added" RelatedID="9b03c9d3-3dd5-4861-b7e3-75d3eca6aaab" /> </EventDetails> </Event> </Events> <Locked>false</Locked> </Application> </Applications> <TransmittalResult Status="OK" /> </Transmittal>