Each member added to the Policy will be enrolled in the following assigned (non-contributory) benefits for this billing category. Dependent coverage, if applicable, is subject to the plan's dependent requirements.

Policy: 00 123456-ABC Company      Division: 0001-ABC 1      Billing Category: 0100


Assigned Benefits
Benefit Plan ID Description
1A BASIC LIFE
1B BASIC ACCIDENTAL DEATH & DISMEMBERMENT

To submit your changes, select View Change Summary from the menu options.