{"text_format":"1","workbook":"xlsx","n_sheets":8,"sheets":["Helpful Hints","Enrollment Worksheet","Beneficiary Sheet","Hidden Enrollment Data","CONFIGURATION","Sheet1","Waiver","Plans"],"not_rendered":{"charts":0,"images":1,"macros":1,"external_links":0,"defined_names":9,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Helpful Hints","index":0,"n_rows":19,"n_cols":3,"rows_kept":19,"cut":false,"hidden":false,"merged":[[18,2,18,9],[5,1,5,12],[7,1,7,12],[11,1,11,12],[2,1,2,12],[9,1,9,12],[13,1,13,12],[15,1,15,12]]}
["Production Date: June 2024"]
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[null,"Enrollment Worksheet Helpful Hints"]
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["1.","You will notice the labeled tabs in the bottom left-hand side of this worksheet. Currently you are in the Helpful Hints tab. The other four tabs are titled  Enrollment Worksheet, Beneficiary Designation and Waiver. To move to another sheet, simply click on the desired tab."]
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["2.","If the information entered is longer than the cell allows, an error will appear indicating the number of characters allowed. PLUM fields need your attention. If a field is not needed (address for a spouse or other non-employee relationship, for example), the cell will be white. White fields should not contain membership information and can be left blank."]
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["3.","Navigation tip: use the \"Tab\" key to move to the right across the sheet.  To move down, use the \"Enter\" key.  To return to the first column, use the \"Home\" key.  You may also use the arrow keys to navigate the spreadsheet."]
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["4.","Please do not use any special characters in group name, employee names, occupations etc."]
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["5.","If you need more lines to enter employees, hold the \"control\" and \"L\" keys, and an additional 250 lines will appear.  Note: If you add more than 500 lines, your cursor will be returned to row 257. Simply scroll down to 507 to continue entering data."]
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["6.","The spreadsheet is set to print two pages wide and seven pages long.  To adjust the size, go to \"File, Page Setup.\"  In the middle of the box, click on \"Adjust To\" and then increase or decrease the percentage size."]
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[null,null,"To print this page: click File, Print."]

{"sheet":"Enrollment Worksheet","index":1,"n_rows":6,"n_cols":94,"rows_kept":6,"cut":false,"hidden":false,"merged":[[1,6,1,7],[1,8,1,11],[4,13,5,13],[4,14,5,14],[4,6,5,6],[4,7,5,7],[4,8,5,8],[3,3,3,42],[4,17,5,17],[4,9,5,9],[4,12,5,12],[4,26,4,30],[4,36,4,38],[4,31,4,35],[4,39,4,42],[4,15,5,15],[4,0,5,0],[4,1,5,1],[4,2,5,2],[4,3,5,3],[4,4,5,4],[4,16,5,16],[4,10,5,10],[4,11,5,11],[4,5,5,5],[4,18,5,18],[4,19,5,19],[4,20,5,20],[4,21,5,21],[4,22,4,25],[4,43,4,44],[4,45,4,48],[4,75,5,75],[4,55,5,55],[4,56,4,58],[4,61,4,62],[4,63,4,65],[4,66,4,74]]}
[null,null,null,null,null,null,null,"State:","KY","Effective date:\n(mm/dd/yyyy)","2024-07-01",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,55,1,1,55,{"$f":"IF(Plans!D7=\"\",Plans!C7,Plans!D7)","v":"Medical Plan"},"plan 1",null,1,55,"Plan 1",null,null,10,"Plan 1 Name","Plan 1"]
[null,"Eligible","Cobra/\nContinuation","Retiree",null,null,"Business Name:",null,"New Group",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,2,null,{"$f":"IF(Plans!D8=\"\",Plans!C8,Plans!D8)","v":"Plan 2"},"plan 2",null,2,"Enroll",1,1]
[null,{"$f":"COUNTIF(C7:C999,\"Active\")","v":0},{"$f":"SUM(COUNTIF(C7:C999,\"Continuation\"),COUNTIF(C7:C999,\"Cobra\"))","v":0},{"$f":"COUNTIF(C7:C999,\"Retiree\")","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3,3,null,{"$f":"IF(Plans!D9=\"\",Plans!C9,Plans!D9)","v":"Plan 3"},null,null,3,"Waive",2,null,null,null,null,null,null,null,"No"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,100,100,null,null,4,null,null,{"$f":"IF(Plans!D10=\"\",Plans!C10,Plans!D10)","v":"Plan 4"},null,null,4," ",3,null,null,null,null,null,null,null,"Yes"]
["Sequence Number","Relationship\n\n(select from drop down list)","Status Field\n\n(select from drop down list)","Social Security Number\n\n(no dashes)","Title           (please click in cell to select from drop down list)","Social Security Number\n\n(no dashes)","Member Last Name","Member First Name","Middle\nInitial","Gender\n\n(select from drop down list)","Date of Birth\n\n(mm/dd/yyyy)","Date of Hire\n\n(mm/dd/yyyy)","Member Street Address\n\n(must be US addresses) ","City","State\n\n(select from drop down list)","Zip Code\n\n(5 or 9 digits, no dashes)","Phone number\n\n(numeric only, no dashes or slashes)","Salary\n\n(annual)","Hours Worked per week","E-Mail Address","Occupation","Disabled? \n\n(select from drop down list)","If member is eligible for, or currently on MEDICARE, please provide:",null,null,null,"MEDICAL",null,null,null,null,"If member had Medical coverage within the past 18 months, please provide:  (if no coverage, enter NONE in carrier name field)",null,null,null,null,"DENTAL",null,null,"If a member had dental and/or ortho coverage within the past 12 months, please provide: \n(if no coverage, enter NONE in carrier name field)",null,null,null,"VISION",null,"LIFE",null,null,null,"Dependent Basic LIFE","Employee Voluntary LIFE","Spousal Voluntary LIFE","Dependent Voluntary LIFE","LTD","STD","Tobacco Status\n\n  (select from drop down list)","Critical Illness",null,null,"Accident","Supplemental Health ","Term Life",null,"Workplace Voluntary Disability",null,null,"Spending Accounts",null,null,null,null,null,null,null,null,"Working Location \n\n(Enter the Location Number from the Sold Quote)",null,null,null,null,{"$f":"IF(Plans!D11=\"\",Plans!C11,Plans!D11)","v":"Plan 5"},null,null,null," ",4]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," Part\n\n(select from drop down list)   "," HICN/Medicare ID #\n\n(no dashes)     ","Effective date\n\n(mm/dd/yyyy)","Term date\n\n(mm/dd/yyyy)","Health Savings Account\n\n(select from drop down list - if not electing an HSA, leave blank)","If Employee is electing MEDICAL, please select Plan\n\n(select from drop down list)","MEDICAL Coverage Type\n\n(select from drop down list)","MEDICAL Provider Name\n\n(only requested for those electing the HMO)","MEDICAL Provider Number","Type of coverage under prior carrier  \n(please click in cell to select from drop down list)","Carrier Name","Policy #","Effective Date\n\n(mm/dd/yyyy)\n\nEnter dashes/slashes in date","Termination Date\n\n(if still in effect, leave blank)\n \n(mm/dd/yyyy)\n\nEnter dashes/slashes in date","If Employee is electing DENTAL, please select Plan\n\n(select from drop down list)","DENTAL Coverage Type\n\n(select from drop down list)","DHMO Provider Name","Prior/Current Carrier Name","Effective Date\n\n(mm/dd/yyyy)","Termination Date - if still in effect, leave blank\n \n(mm/dd/yyyy)","Was orthodontia included?\n\n(select from drop down list)","If Employee is electing VISION, please select Plan\n\n(select from drop down list)","VISION Coverage Type\n\n(select from drop down list)","Basic Life Election\n\n\n(select from drop down list)","If by Salary, please indicate Salary plan\n\n(select from drop down list)","Basic Life - Flat Amount\n\n(select from drop down list)","Primary Life Beneficiary\n\n(please enter only one)","Enroll or Waive\n\n(select from drop down list)","Amount\n\nFlat Amount  - \nIf not electing, enter \"Waive\"","Amount\n\nFlat Amount  - If not electing, enter \"Waive\"","\n(select from drop down list)","\nIf  100% Employer Paid, requires 100% Participation\n\n(select from drop down list)","\nIf  100% Employer Paid, requires 100% Participation\n\n(select from drop down list)",null,"Critical Illness Employee Benefit \n \n(select from drop down list)","Critical Illness -  Spouse\n \n (select from drop down list)","Critical Illness -  Child \n\n (select from drop down list)","Plan Option\n \n(select from drop down list)","Plan Option \n\n(select from drop down list)","Term Life Amount\n\n(select from drop down list)","Term Life Duration\n\n(select from drop down list, leave blank if waiving)","Disability Benefit\n\n(enter amount, leave blank to waive)","Elimination Period\n\n(select from drop down list, leave blank if waiving)","Benefit Duration\n","Writing Agent #1\nName","Writing Agent #1\nSAN","Writing Agent #1\nSplit (%)\n\n(If split, must equal 100%)","Writing Agent #2\nName","Writing Agent #2\nSAN","Writing Agent #2\nSplit (%)\n\n(If split, must equal 100%)","Health Reimbursement Arrangement\n(HRA)","Flexible Spending Account\n(FSA)","Dependent Care FSA",null,null,null,null,null,{"$f":"IF(Plans!D12=\"\",Plans!C12,Plans!D12)","v":"Plan 6"},null,null,"Waive"," ","Waive"]

{"sheet":"Beneficiary Sheet","index":2,"n_rows":42,"n_cols":1,"rows_kept":42,"cut":false,"hidden":false,"merged":[[26,0,26,8],[29,0,34,8],[41,0,41,8],[14,0,14,8],[16,0,16,8],[18,0,18,8],[20,0,20,8],[22,0,22,8],[24,0,24,8],[12,0,12,8],[0,0,0,8],[3,0,3,8],[5,0,5,8],[8,0,8,8],[10,0,10,8]]}
["HumanaLife Beneficiary Designation Form"]
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[]
["Employee Name (Please print)  ______________________________________"]
[]
["Employee Social Security Number  ___________________________________"]
[]
[]
["Primary Beneficiary Designation:"]
[]
["Name _________________________________ Relationship  _______________"]
[]
["    Address of Beneficiary ______________________________________________"]
[]
["    Percentage  _________________________"]
[]
["Name _________________________________ Relationship  _______________"]
[]
["    Address of Beneficiary ______________________________________________"]
[]
["    Percentage  _________________________"]
[]
["Secondary Beneficiary Designation:"]
[]
["Name _________________________________ Relationship  _______________"]
[]
["    Address of Beneficiary ______________________________________________"]
[]
[]
["If two or more primary beneficiaries are named, and you do not list benefit percentages, proceeds will be paid in equal shares to the named primary beneficiaries who survive you.  If no primary beneficiary survives you, proceeds will be paid to the contingent beneficiaries.  If no designated beneficiary survives you, the beneficiary will be determined according to the provisions of the group life insurance contract."]
[]
[]
[]
[]
[]
[]
[]
["Employee Signature  ___________________________   Date Signed  ________"]
[]
[]
[]
["This form needs to be provided to Humana prior to, or at the time of claim."]

{"sheet":"Hidden Enrollment Data","index":3,"n_rows":10000,"n_cols":39,"rows_kept":10000,"cut":false,"hidden":true,"merged":[]}
[]
[]
[]
[]
[]
["State Code","Sequence Number","Group Data","Medical Plan Name","Medical Plan Code","Dental Plan Name","Dental Plan Code","Vision Plan Name","Vision Plan Code","Accident Plan Name","Accident Plan Code","LTD Plan Code","STD Plan Code","Basic Life By Class","Demographic Ind","Product Ind","Medical Plan Ind"," Dental Plan Ind"," Vision Plan Ind"," Basic Life By Class Ind"," Basic Life By Salary Ind"," Basic Life Volume Ind","Dependent Basic Life Ind","Employee Voluntary Life Ind","Dependent Voluntary Life Ind","LTD Ind","STD Ind"," Accident Plan Ind","Disability Income Plus Covering Accident & Sickness w/Waiver Ind","Disability Income Plus Covering Accident & Sickness Ind","Disability Income Advantage Ind","Whole Life Ind","Level Term Life Ind","Critical Illness Ind","Critical Illness & Cancer Ind","Cancer Lump Sum Ind","Cancer Expanse Ind","Supplemental Health Ind","Spousal Voluntary Life Ind"]
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{"sheet":"CONFIGURATION","index":4,"n_rows":51,"n_cols":25,"rows_kept":51,"cut":false,"hidden":true,"merged":[[42,0,42,1],[3,0,3,3],[15,0,15,3],[9,0,9,3],[3,5,3,10],[21,0,21,2],[24,5,27,5],[28,5,31,5],[32,5,33,5]]}
["BUSINESS NAME","GROUP NUMBER","EFFECTIVE DATE","REASON FOR COVERAGE CHANGE","FILE SUBMITTED BY",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"V:\\admshare\\Plan Change\\Heidi\\TroyTest"]
["New Group",null,"2024-07-01",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Open Enrollment","STD","AL",{"$f":"CONCATENATE(Y3,Y4,Y5)","v":"listenrollment_20240"}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Gain/Loss of Other Coverage","LTD","AK","listenrollment_"]
["MEDICAL PLAN NAME IDENTIFIERS",null,null,null,"ENROLL?","ADDITIONAL MEDICAL PLAN NAME IDENTIFIERS (IL)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"SALARY BASED LIFE","AZ",{"$f":"YEAR(TODAY())","v":2024}]
["Plan 1","Plan 2","Plan 3","Plan 4",null,"Plan 5","Plan 6","Plan 7","Plan 8","Plan 9","Plan 10",null,null,null,null,null,null,null,null,null,null,null,null,"AR",{"$f":"B2","v":0}]
["HRBADESCRIPTION1","HRBADESCRIPTION2","HRBADESCRIPTION3","HRBADESCRIPTION4",null,"HRBADESCRIPTION5","HRBADESCRIPTION6","HRBADESCRIPTION7","HRBADESCRIPTION8","HRBADESCRIPTION9","HRBADESCRIPTION10",null,null,null,null,null,null,null,null,null,null,null,null,"CA",{"$f":"DAY(C2)","v":1}]
["Medical Plan",null,null,null,null,"DESC IN COLUMN AB OF LE","DESC IN COLUMN AB OF LE","DESC IN COLUMN AB OF LE","DESC IN COLUMN AB OF LE","DESC IN COLUMN AB OF LE","DESC IN COLUMN AB OF LE",null,null,null,null,null,null,null,null,null,null,null,null,"CO"]
[null,"*",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CT"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DE"]
["DENTAL PLAN NAME INDENTIFIERS",null,null,null,"ENROLL?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FL"]
["Plan 1","Plan 2","Plan 3","Plan 4",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"GA"]
["HRBADESCRIPTION1","HRBADESCRIPTION2","HRBADESCRIPTION3","HRBADESCRIPTION4",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"HI"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ID"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"IL"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"IN"]
["VISION PLAN NAME IDENTIFIERS",null,null,null,"ENROLL?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"IA"]
["Plan1","Plan 2","Plan 3","Plan 4","X",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"KS"]
["HRBADESCRIPTION1","HRBADESCRIPTION2","HRBADESCRIPTION3","HRBADESCRIPTION4",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"KY"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"LA"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ME"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MD"]
["BASIC LIFE",null,null,"ENROLL?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MA"]
["BASIC LIFE IF BY FLAT AMOUNT","BASIC LIFE IF BY SALARY","BASIC LIFE IF BY CLASS","X",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MI"]
["15000 (OR) 15K","See Dropdown in Column AU for examples","Example: Class 1",null,null,"Validation",null,null,"Employee","Employee + Spouse","Employee + Child(ren)","Family",null,null,null,null,null,null,null,null,null,null,null,"MN"]
[null,null,"Example: Class 2",null,null,"Medical","Plan 1",{"$f":"CONCATENATE(A5,\"/\",A6)","v":"Plan 1/HRBADESCRIPTION1"},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B505,\"=Employee\",'Enrollment Worksheet'!AC6:AC505,\"=Employee\",'Enrollment Worksheet'!AB6:AB505,Plans!D7)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B505,\"=Employee\",'Enrollment Worksheet'!AC6:AC505,\"=Employee + Spouse\",'Enrollment Worksheet'!AB6:AB505,Plans!D7)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B505,\"=Employee\",'Enrollment Worksheet'!AC6:AC505,\"=Employee + Child(ren)\",'Enrollment Worksheet'!AB6:AB505,Plans!D7)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B505,\"=Employee\",'Enrollment Worksheet'!AC6:AC505,\"=Family\",'Enrollment Worksheet'!AB6:AB505,Plans!D7)","v":0},null,null,null,null,null,null,null,null,null,null,null,"MS"]
[null,null,"Example: Class 3",null,null,null,"Plan 2",{"$f":"CONCATENATE(B5,\"/\",B6)","v":"Plan 2/HRBADESCRIPTION2"},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B505,\"=Employee\",'Enrollment Worksheet'!AC6:AC505,\"=Employee\",'Enrollment Worksheet'!AB6:AB505,Plans!D8)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B505,\"=Employee\",'Enrollment Worksheet'!AC6:AC505,\"=Employee + Spouse\",'Enrollment Worksheet'!AB6:AB505,Plans!D8)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B505,\"=Employee\",'Enrollment Worksheet'!AC6:AC505,\"=Employee + Child(ren)\",'Enrollment Worksheet'!AB6:AB505,Plans!D8)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B505,\"=Employee\",'Enrollment Worksheet'!AC6:AC505,\"=Family\",'Enrollment Worksheet'!AB6:AB505,Plans!D8)","v":0},null,null,null,null,null,null,null,null,null,null,null,"MO"]
[null,null,"Example: Class 4",null,null,null,"Plan 3",{"$f":"CONCATENATE(C5,\"/\",C6)","v":"Plan 3/HRBADESCRIPTION3"},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B505,\"=Employee\",'Enrollment Worksheet'!AC6:AC505,\"=Employee\",'Enrollment Worksheet'!AB6:AB505,Plans!D9)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B505,\"=Employee\",'Enrollment Worksheet'!AC6:AC505,\"=Employee + Spouse\",'Enrollment Worksheet'!AB6:AB505,Plans!D9)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B505,\"=Employee\",'Enrollment Worksheet'!AC6:AC505,\"=Employee + Child(ren)\",'Enrollment Worksheet'!AB6:AB505,Plans!D9)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B505,\"=Employee\",'Enrollment Worksheet'!AC6:AC505,\"=Family\",'Enrollment Worksheet'!AB6:AB505,Plans!D9)","v":0},null,null,null,null,null,null,null,null,null,null,null,"MT"]
[null,null,"Example: Class 5",null,null,null,"Plan 4",{"$f":"CONCATENATE(D5,\"/\",D6)","v":"Plan 4/HRBADESCRIPTION4"},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B505,\"=Employee\",'Enrollment Worksheet'!AC6:AC505,\"=Employee\",'Enrollment Worksheet'!AB6:AB505,Plans!D10)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B505,\"=Employee\",'Enrollment Worksheet'!AC6:AC505,\"=Employee + Spouse\",'Enrollment Worksheet'!AB6:AB505,Plans!D10)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B505,\"=Employee\",'Enrollment Worksheet'!AC6:AC505,\"=Employee + Child(ren)\",'Enrollment Worksheet'!AB6:AB505,Plans!D10)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B505,\"=Employee\",'Enrollment Worksheet'!AC6:AC505,\"=Family\",'Enrollment Worksheet'!AB6:AB505,Plans!D10)","v":0},null,null,null,null,null,null,null,null,null,null,null,"NE"]
["VOLUNTARY LIFE","ENROLL?","Example: Class 6",null,null,"Dental","Plan 1",{"$f":"CONCATENATE(A11,\"/\",A12)","v":"Plan 1/HRBADESCRIPTION1"},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B509,\"=Employee\",'Enrollment Worksheet'!AL6:AL509,\"=Employee\",'Enrollment Worksheet'!AK6:AK509,Plans!I7)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B509,\"=Employee\",'Enrollment Worksheet'!AL6:AL509,\"=Employee + Spouse\",'Enrollment Worksheet'!AK6:AK509,Plans!I7)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B509,\"=Employee\",'Enrollment Worksheet'!AL6:AL509,\"=Employee + Child(ren)\",'Enrollment Worksheet'!AK6:AK509,Plans!I7)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B509,\"=Employee\",'Enrollment Worksheet'!AL6:AL509,\"=Family\",'Enrollment Worksheet'!AK6:AK509,Plans!I7)","v":0},null,null,null,null,null,null,null,null,null,null,null,"NV"]
[null,"X","Example: Class 7",null,null,null,"Plan 2",{"$f":"CONCATENATE(B11,\"/\",B12)","v":"Plan 2/HRBADESCRIPTION2"},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B509,\"=Employee\",'Enrollment Worksheet'!AL6:AL509,\"=Employee\",'Enrollment Worksheet'!AK6:AK509,Plans!I8)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B509,\"=Employee\",'Enrollment Worksheet'!AL6:AL509,\"=Employee + Spouse\",'Enrollment Worksheet'!AK6:AK509,Plans!I8)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B509,\"=Employee\",'Enrollment Worksheet'!AL6:AL509,\"=Employee + Child(ren)\",'Enrollment Worksheet'!AK6:AK509,Plans!I8)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B509,\"=Employee\",'Enrollment Worksheet'!AL6:AL509,\"=Family\",'Enrollment Worksheet'!AK6:AK509,Plans!I8)","v":0},null,null,null,null,null,null,null,null,null,null,null,"NH"]
[null,null,"Example: Class 8",null,null,null,"Plan 3",{"$f":"CONCATENATE(C11,\"/\",C12)","v":"Plan 3/HRBADESCRIPTION3"},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B509,\"=Employee\",'Enrollment Worksheet'!AL6:AL509,\"=Employee\",'Enrollment Worksheet'!AK6:AK509,Plans!I9)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B509,\"=Employee\",'Enrollment Worksheet'!AL6:AL509,\"=Employee + Spouse\",'Enrollment Worksheet'!AK6:AK509,Plans!I9)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B509,\"=Employee\",'Enrollment Worksheet'!AL6:AL509,\"=Employee + Child(ren)\",'Enrollment Worksheet'!AK6:AK509,Plans!I9)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B509,\"=Employee\",'Enrollment Worksheet'!AL6:AL509,\"=Family\",'Enrollment Worksheet'!AK6:AK509,Plans!I9)","v":0},null,null,null,null,null,null,null,null,null,null,null,"NJ"]
["HRA","ENROLL?","Example: Class 9",null,null,null,"Plan 4",{"$f":"CONCATENATE(D11,\"/\",D12)","v":"Plan 4/HRBADESCRIPTION4"},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B509,\"=Employee\",'Enrollment Worksheet'!AL6:AL509,\"=Employee\",'Enrollment Worksheet'!AK6:AK509,Plans!I10)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B509,\"=Employee\",'Enrollment Worksheet'!AL6:AL509,\"=Employee + Spouse\",'Enrollment Worksheet'!AK6:AK509,Plans!I10)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B509,\"=Employee\",'Enrollment Worksheet'!AL6:AL509,\"=Employee + Child(ren)\",'Enrollment Worksheet'!AK6:AK509,Plans!I10)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B509,\"=Employee\",'Enrollment Worksheet'!AL6:AL509,\"=Family\",'Enrollment Worksheet'!AK6:AK509,Plans!I10)","v":0},null,null,null,null,null,null,null,null,null,null,null,"NM"]
[null,null,"Example: Class 10",null,null,"Vision","Plan 1",{"$f":"CONCATENATE(A17,\"/\",A18)","v":"Plan1/HRBADESCRIPTION1"},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B513,\"=Employee\",'Enrollment Worksheet'!AS6:AS513,\"=Employee\",'Enrollment Worksheet'!AR6:AR513,Plans!K7)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B513,\"=Employee\",'Enrollment Worksheet'!AS6:AS513,\"=Employee + Spouse\",'Enrollment Worksheet'!AR6:AR513,Plans!K6)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B513,\"=Employee\",'Enrollment Worksheet'!AS6:AS513,\"=Employee + Child(ren)\",'Enrollment Worksheet'!AR6:AR513,Plans!K6)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B513,\"=Employee\",'Enrollment Worksheet'!AS6:AS513,\"=Family\",'Enrollment Worksheet'!AR6:AR513,Plans!K6)","v":0},null,null,null,null,null,null,null,null,null,null,null,"NY"]
[null,null,null,null,null,null,"Plan 2",{"$f":"CONCATENATE(B17,\"/\",B18)","v":"Plan 2/HRBADESCRIPTION2"},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B513,\"=Employee\",'Enrollment Worksheet'!AS6:AS513,\"=Employee\",'Enrollment Worksheet'!AR6:AR513,Plans!K8)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B513,\"=Employee\",'Enrollment Worksheet'!AS6:AS513,\"=Employee + Spouse\",'Enrollment Worksheet'!AR6:AR513,Plans!K7)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B513,\"=Employee\",'Enrollment Worksheet'!AS6:AS513,\"=Employee + Child(ren)\",'Enrollment Worksheet'!AR6:AR513,Plans!K7)","v":0},{"$f":"COUNTIFS('Enrollment Worksheet'!B6:B513,\"=Employee\",'Enrollment Worksheet'!AS6:AS513,\"=Family\",'Enrollment Worksheet'!AR6:AR513,Plans!K7)","v":0},null,null,null,null,null,null,null,null,null,null,null,"NC"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ND"]
["FSA","ENROLL?","STD IF BY CLASS","ENROLL?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"OH"]
["FSH",null,"Example: Class 1","X",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"OK"]
["FSD",null,"Example: Class 2",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"OR"]
[null,null,"Example: Class 3",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PA"]
["H.S.A.","ENROLL?","Example: Class 4",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RI"]
[null,null,"Example: Class 5",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"SC"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"SD"]
["ELIGIBILITY GROUP",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TN"]
["MULTIPLE LOCATION IDENTIFIER (BX)","HRBA IDENTIFIER","LTD IF BY CLASS","ENROLL?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TX"]
[1,"HRBA 1","Example: Class 1",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"UT"]
[2,"HRBA 2","Example: Class 2",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VT"]
[3,"HRBA 3","Example: Class 3",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VA"]
[4,"HRBA 4","Example: Class 4",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"WA"]
[null,null,"Example: Class 5",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"WV"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"WI"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"WY"]

{"sheet":"Sheet1","index":5,"n_rows":0,"n_cols":0,"rows_kept":0,"cut":false,"hidden":true,"merged":[]}

{"sheet":"Waiver","index":6,"n_rows":32,"n_cols":7,"rows_kept":32,"cut":false,"hidden":false,"merged":[[31,0,31,3],[0,0,0,7],[1,0,1,7],[3,0,3,7],[15,0,15,4],[29,0,29,3]]}
["Waiver (refusal of coverage)"]
["I acknowledge that I have been given the opportunity to apply for group coverage available to me and my dependents through my employer.  I proclaim that I was not pressured or forced by my employer, the writing agent, or Humana into waiving (declining) coverage.  If I have waived any coverage offered to me or my dependents, my signature is evidence of this action."]
[]
["I hereby waive coverage for (check all that apply):"]
[]
["Medical for: ",null,"Myself",null,"My spouse",null,"My dependent child(ren)"]
[]
["Dental for:",null,"Myself",null,"My spouse",null,"My dependent child(ren)"]
[]
["Basic Life for:",null,"Myself",null,"My spouse",null,"My dependent child(ren)"]
[]
["Vision for",null,"Myself",null,"My spouse",null,"My dependent child(ren)"]
[]
["Health Savings Account for:",null,"Myself",null,"My spouse",null,"My dependent child(ren)"]
[]
["I decline to apply for group coverage because of:"]
[]
[null,null,"Spousal coverage"]
[]
[null,null,"Medicare supplement"]
[]
[null,null,"Individual coverage"]
[]
[null,null,"Coverage under another carrier's plan provided by my employer"]
[]
[null,null,"Other:"]
[]
[]
[]
["Employee or legal respresentative signature:"]
[]
["Name and relationship of legal representative:"]

{"sheet":"Plans","index":7,"n_rows":17,"n_cols":19,"rows_kept":17,"cut":false,"hidden":true,"merged":[[2,3,4,3]]}
[]
[]
[null,null,null,"Please indicate an identifiable plan name or reference number from the sold quote (preferred). This will appear on the list enrollment in order to designate the plan each employee elects."]
[]
[]
[null,null,"Plan #","Name/Reference#",null,null,null,null,"DENTAL PLAN",null,"VISION PLAN",null,"STD",null,"LTD",null,"LIFE","Yes","VolDepLife"]
[null,null,"Plan 1","Medical Plan",null,null,null,null,null,null,"Vision",null,1,null,1,null,1,"No",10000]
[null,null,"Plan 2",null,null,null,null,null,null,null,null,null,2,null,2,null,2,null,"Waive"]
[null,null,"Plan 3",null,null,null,null,null,null,null,null,null,3,null,3,null,3]
[null,null,"Plan 4",null,null,null,null,null,null,null,null,null,4,null,4,null,4]
[null,null,"Plan 5",null,null,null,null,null,null,null,null,null,5,null,5,null,5]
[null,null,"Plan 6",null,null,null,null,null,null,null,null,null,"Waive",null,"Waive",null,6]
[null,null,"Plan 7",null,null,null,null,null,null,null,null,null,null,null,null,null,7]
[null,null,"Plan 8",null,null,null,null,null,null,null,null,null,null,null,null,null,8]
[null,null,"Plan 9",null,null,null,null,null,null,null,null,null,null,null,null,null,9]
[null,null,"Plan 10",null,null,null,null,null,null,null,null,null,null,null,null,null,10]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Waive"]