[ { "page": 1, "items": [ { "page": 1, "type": "TEXT", "location": { "l": 36.48, "t": 733.68, "r": 561.12, "b": 697.96 }, "text": "SECTION I – EMPLOYEE INFORMATION AND COVERAGE ELECTION", "reading_order": 0 }, { "page": 1, "type": "TEXT", "location": { "l": 36.48, "t": 697.96, "r": 561.12, "b": 662.24 }, "text": "Employer Name DUBUQUE COUNTY Group # 2202 Division Plan", "reading_order": 1 }, { "page": 1, "type": "TEXT", "location": { "l": 36.48, "t": 662.24, "r": 561.12, "b": 626.52 }, "text": "Name (First, MI, Last) Social Security #_____. Hire Date ____/____/____", "reading_order": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 36.48, "t": 626.52, "r": 561.12, "b": 590.8 }, "text": "Street Address Telephone Effective Date ____/____/____", "reading_order": 3 }, { "page": 1, "type": "TEXT", "location": { "l": 36.48, "t": 590.8, "r": 561.12, "b": 555.08 }, "text": "City State Zip Date of Birth ____/____/____ Email address", "reading_order": 4 }, { "page": 1, "type": "TEXT", "location": { "l": 36.48, "t": 555.08, "r": 561.12, "b": 519.36 }, "text": "☐ Male ☐ Female Marital Status ☐ Married ☐ Single ☐ Divorced ☐ Legally Separated ☐ Widow/Widower", "reading_order": 5 }, { "page": 1, "type": "TEXT", "location": { "l": 36.48, "t": 519.36, "r": 561.12, "b": 483.64 }, "text": "Reason for Completing this Form", "reading_order": 6 }, { "page": 1, "type": "TOC", "location": { "l": 43.2, "t": 512.1551, "r": 523.3903, "b": 359.3766 }, "text": "", "items": [ { "page": 1, "type": "TOC_ITEM", "location": { "l": 43.2, "t": 504.1989, "r": 523.3903, "b": 492.8167 }, "text": "Spouse ❑ Spouse (lawful) ❑", "title": "Spouse ❑ Spouse (lawful) ❑", "page_target": null, "page_start": null, "page_end": null, "row_index": 0, "reading_order": 0 } ], "reading_order": 7 }, { "page": 1, "type": "TEXT", "location": { "l": 36.48, "t": 483.64, "r": 561.12, "b": 447.92 }, "text": "Medical & Vision ☐ Single ☐ Family ☐ Decline ☐ New Hire ☐ Late Enrollment ☐ Marriage/Birth/Adoption ☐ Terminate Coverage for one/all dependents ☐ List dependents who are no longer covered ☐ Part/Full-time Change ☐ Special Enrollment/Loss of Coverage Date Coverage lost _____ ☐ Voluntary or ☐ Lost other coverage Date of Event/Change ____/____/____", "reading_order": 8 }, { "page": 1, "type": "TOC_ITEM", "location": { "l": 228.65, "t": 478.4562, "r": 523.3903, "b": 465.7542 }, "text": "❑ Step Child ❑", "value": "M", "reading_order": 9 }, { "page": 1, "type": "TEXT", "location": { "l": 36.48, "t": 447.92, "r": 561.12, "b": 412.2 }, "text": "SECTION II – ELIGIBLE DEPENDENTS INFORMATION Note: This application does not guarantee coverage.", "reading_order": 10 }, { "page": 1, "type": "TOC_ITEM", "location": { "l": 228.65, "t": 443.0562, "r": 523.3903, "b": 430.3542 }, "text": "❑ Step Child ❑", "value": "M", "reading_order": 11 }, { "page": 1, "type": "TEXT", "location": { "l": 36.48, "t": 412.2, "r": 561.12, "b": 376.48 }, "text": "Name (First, MI, Last) Relationship Social Security #-(SSN) Federal law MMSEA requires collection of SSN for all dependents Date Of Birth Gender", "reading_order": 12 }, { "page": 1, "type": "TOC_ITEM", "location": { "l": 228.65, "t": 407.7762, "r": 523.3903, "b": 395.0742 }, "text": "❑ Step Child ❑", "value": "M", "reading_order": 13 }, { "page": 1, "type": "TEXT", "location": { "l": 36.48, "t": 376.48, "r": 561.12, "b": 340.76 }, "text": "Spouse ☐ Spouse (lawful) ☐ Other ☐ M ☐ F", "reading_order": 14 }, { "page": 1, "type": "TOC_ITEM", "location": { "l": 228.65, "t": 369.0789, "r": 523.3903, "b": 359.3766 }, "text": "❑ Step Child ❑", "value": "M", "reading_order": 15 }, { "page": 1, "type": "TITLE", "location": { "l": 309.65, "t": 512.1551, "r": 361.1819, "b": 503.135 }, "text": "for all dependents", "reading_order": 16, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 36.48, "t": 340.76, "r": 561.12, "b": 305.04 }, "text": "Dependent ☐ Natural/Adopted ☐ Step Child ☐ Foster Child ☐ Other ☐ M ☐ F", "reading_order": 17 }, { "page": 1, "type": "TEXT", "location": { "l": 36.48, "t": 305.04, "r": 561.12, "b": 269.32 }, "text": "Dependent ☐ Natural/Adopted ☐ Step Child ☐ Other ☐ M ☐ F", "reading_order": 18 }, { "page": 1, "type": "TEXT", "location": { "l": 36.48, "t": 269.32, "r": 561.12, "b": 233.6 }, "text": "Dependent ☐ Natural/Adopted ☐ Step Child ☐ Foster Child ☐ Other ☐ M ☐ F", "reading_order": 19 }, { "page": 1, "type": "TEXT", "location": { "l": 36.48, "t": 233.6, "r": 561.12, "b": 197.88 }, "text": "Dependent ☐ Natural/Adopted ☐ Step Child ☐ Other ☐ M ☐ F", "reading_order": 20 }, { "page": 1, "type": "TEXT", "location": { "l": 36.48, "t": 197.88, "r": 561.12, "b": 162.16 }, "text": "SECTION III – OTHER COVERAGE Note: This section must be completed for SISCO to process your dependent claims.", "reading_order": 21 }, { "page": 1, "type": "TEXT", "location": { "l": 36.48, "t": 162.16, "r": 561.12, "b": 126.44 }, "text": "PART A: Spouse (if applicable) Date of Marriage PART B: Ex-spouse (if applicable) Divorce Date", "reading_order": 22 }, { "page": 1, "type": "TEXT", "location": { "l": 36.48, "t": 126.44, "r": 561.12, "b": 90.72 }, "text": "Name & City of Employer (this information is for Coordination of Benefits for any dependent children) Ex-Spouse Name(s) _____ Address(es) _____ Social Security # (if available) _____ Name and City of Employer(s) _____ If your ex-spouse has coverage through this employer, _____ 1. Indicate the type of coverage: ☐ Medical ☐ Dental ☐ Prescription Drug ☐ Vision 2. What date did this coverage become effective? _____ 3. List the children covered under this plan _____ 4. List the children covered under this plan _____ 5. List the children covered under this plan _____ 6. List the children covered under this plan _____ 7. List the children covered under this plan _____ 8. List the children covered under this plan _____ 9. List the children covered under this plan _____ 10. List the children covered under this plan _____ 11. List the children covered under this plan _____ 12. List the children covered under this plan _____ 13. List the children covered under this plan _____ 14. List the children covered under this plan _____ 15. List the children covered under this plan _____ 16. List the children covered under this plan _____ 17. List the children covered under this plan _____ 18. List the children covered under this plan _____ 19. 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List the children covered under this plan _____ 1040. List the children covered under this plan _____ 1041. List the children covered under this plan _____ 1042. List the", "reading_order": 23 }, { "page": 1, "type": "TEXT", "location": { "l": 41.76, "t": 89.76, "r": 154.32, "b": 81.12 }, "text": "Enroll 1 Medical/Dental 4 Levels 2010", "reading_order": 24 }, { "page": 1, "type": "TEXT", "location": { "l": 257.04, "t": 89.76, "r": 508.8, "b": 80.64 }, "text": "Self Insured Services Company Phone 800-457-4726 Enrollment Department Ext. 5420", "reading_order": 25 } ] } ]