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<?xml version="1.0" encoding="UTF-8"?> <structure version="2" schemafile="http://www.altova.com/Schemas/hr-xml/Enrollment-2_0.xsd" workingxmlfile="" templatexmlfile="Enrollment-template.xml"> <nspair prefix="n1" uri="http://ns.hr-xml.org/Enrollment/Enrollment-2_0"/> <nspair prefix="xsd" uri="http://www.w3.org/2001/XMLSchema"/> <template> <styles font-family="Tahoma"/> <match overwrittenxslmatch="/"/> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-bottom-color="#2018A7" border-bottom-style="solid" border-bottom-width="thin"/> <properties align="left" height="60" valign="top"/> <children> <text fixtext="Enrollment"> <styles font-family="Tahoma" font-weight="bold"/> </text> <newline/> <newline/> <image> <properties border="0"/> <imagesource> <fixtext value="info-15x15.gif"/> </imagesource> </image> <text fixtext=" Enrollment is used as a root element, is in all instance documents and is created automaticly by authentic"> <styles font-family="Tahoma"/> </text> <newline/> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:Enrollment"/> <children> <table> <properties bgcolor="#F8DC89" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties align="left" width="597"/> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties colspan="2" height="28" width="170"/> <children> <text fixtext="Transaction Type: "> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-bottom-color="#AAAAAA" border-bottom-style="solid" border-bottom-width="thin" border-left-color="#AAAAAA" border-left-style="solid" border-left-width="thin" border-right-color="#AAAAAA" border-right-style="solid" border-right-width="thin" border-top-color="#AAAAAA" border-top-style="solid" border-top-width="thin"/> <properties align="left" height="28" width="127"/> <children> <text fixtext=" "> <styles font-family="Tahoma"/> </text> <template> <match match="@transactionType"/> <children> <select ownvalue="1"> <styles font-family="Tahoma"/> <properties size="0"/> <selectoption description="Change" value="Change"/> <selectoption description="Full" value="Full"/> </select> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties colspan="2" width="170"/> <children> <text fixtext="Creation Date:"> <styles font-family="Tahoma"/> </text> <text fixtext=" "> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-bottom-color="#AAAAAA" border-bottom-style="solid" border-bottom-width="thin" border-left-color="#AAAAAA" border-left-style="solid" border-left-width="thin" border-right-color="#AAAAAA" border-right-style="solid" border-right-width="thin" border-top-color="#AAAAAA" border-top-style="solid" border-top-width="thin"/> <properties width="333"/> <children> <text fixtext=" "> <styles font-family="Tahoma"/> </text> <template> <match match="@creationDate"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> <newline/> <text fixtext="Format: CCYY-MM-DDTHH:MM:SS-HH:MM"> <styles font-family="Tahoma" font-size="9pt" font-style="italic" font-weight="bold"/> </text> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties align="left" width="170"/> <children> <text fixtext="Originator Identification:"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-bottom-color="#AAAAAA" border-bottom-style="solid" border-bottom-width="thin" border-left-color="#AAAAAA" border-left-style="solid" border-left-width="thin" border-right-color="#AAAAAA" border-right-style="solid" border-right-width="thin" border-top-color="#AAAAAA" border-top-style="solid" border-top-width="thin"/> <properties width="328"/> <children> <text fixtext=" "> <styles font-family="Tahoma"/> </text> <template> <match match="@originatorId"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Originator Name:"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-bottom-color="#AAAAAA" border-bottom-style="solid" border-bottom-width="thin" border-left-color="#AAAAAA" border-left-style="solid" border-left-width="thin" border-right-color="#AAAAAA" border-right-style="solid" border-right-width="thin" border-top-color="#AAAAAA" border-top-style="solid" border-top-width="thin"/> <properties width="330"/> <children> <text fixtext=" "> <styles font-family="Tahoma"/> </text> <template> <match match="@originatorName"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Baseline Date:"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-bottom-color="#AAAAAA" border-bottom-style="solid" border-bottom-width="thin" border-left-color="#AAAAAA" border-left-style="solid" border-left-width="thin" border-right-color="#AAAAAA" border-right-style="solid" border-right-width="thin" border-top-color="#AAAAAA" border-top-style="solid" border-top-width="thin"/> <properties width="327"/> <children> <template> <match match="@baselineDate"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> <newline/> <text fixtext="Format: CCYY-MM-DDTHH:MM:SS-HH:MM"> <styles font-family="Tahoma" font-size="9pt" font-style="italic" font-weight="bold"/> </text> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Recipient ID:"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-bottom-color="#AAAAAA" border-bottom-style="solid" border-bottom-width="thin" border-left-color="#AAAAAA" border-left-style="solid" border-left-width="thin" border-right-color="#AAAAAA" border-right-style="solid" border-right-width="thin" border-top-color="#AAAAAA" border-top-style="solid" border-top-width="thin"/> <properties width="325"/> <children> <text fixtext=" "> <styles font-family="Tahoma"/> </text> <template> <match match="@recipientId"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Recipient Name:"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-bottom-color="#AAAAAA" border-bottom-style="solid" border-bottom-width="thin" border-left-color="#AAAAAA" border-left-style="solid" border-left-width="thin" border-right-color="#AAAAAA" border-right-style="solid" border-right-width="thin" border-top-color="#AAAAAA" border-top-style="solid" border-top-width="thin"/> <properties align="left" width="326"/> <children> <text fixtext=" "> <styles font-family="Tahoma"/> </text> <template> <match match="@recipientName"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-bottom-color="#2018A7" border-bottom-style="solid" border-bottom-width="thin"/> <children> <text fixtext="Organization"> <styles font-family="Tahoma" font-weight="bold"/> </text> <newline/> <newline/> <image> <properties border="0"/> <imagesource> <fixtext value="info-15x15.gif"/> </imagesource> </image> <text fixtext=" Organization is used to specify the "> <styles font-family="Tahoma"/> </text> <text fixtext="one or more "> <styles font-family="Tahoma" font-style="italic" font-weight="bold"/> </text> <text fixtext="groups to be transmitted this data. It contains two values "Organization Name" and "Organization ID" a could contain two possible elements, "> <styles font-family="Tahoma"/> </text> <text fixtext="one or more "> <styles font-family="Tahoma" font-style="italic" font-weight="bold"/> </text> <text fixtext=" "Subscriber" Elements and possibily BenifitsAdminstrativeAffiliate."> <styles font-family="Tahoma"/> </text> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:Organization"/> <children> <table> <properties bgcolor="#F8DC89" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties height="63"/> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Organization Name:"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-bottom-color="#AAAAAA" border-bottom-style="solid" border-bottom-width="thin" border-left-color="#AAAAAA" border-left-style="solid" border-left-width="thin" border-right-color="#AAAAAA" border-right-style="solid" border-right-width="thin" border-top-color="#AAAAAA" border-top-style="solid" border-top-width="thin"/> <properties width="282"/> <children> <text fixtext=" "> <styles font-family="Tahoma"/> </text> <template> <match match="@organizationName"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Organization ID"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-bottom-color="#AAAAAA" border-bottom-style="solid" border-bottom-width="thin" border-left-color="#AAAAAA" border-left-style="solid" border-left-width="thin" border-right-color="#AAAAAA" border-right-style="solid" border-right-width="thin" border-top-color="#AAAAAA" border-top-style="solid" border-top-width="thin"/> <properties width="278"/> <children> <text fixtext=" "> <styles font-family="Tahoma"/> </text> <template> <match match="@organizationId"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-bottom-color="#2018A7" border-bottom-style="solid" border-bottom-width="thin"/> <children> <text fixtext="Subscriber"> <styles font-family="Tahoma" font-weight="bold"/> </text> <newline/> <image> <properties border="0"/> <imagesource> <fixtext value="info-15x15.gif"/> </imagesource> </image> <text fixtext=" Subscriber element contains detailed information on the individual enrolling with the present organization."> <styles font-family="Tahoma"/> </text> <newline/> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:Subscriber"/> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-left-color="blue" border-left-style="solid" border-left-width="thin" border-top-color="blue" border-top-style="solid" border-top-width="thin"/> <properties width="25"/> <children> <text fixtext=" "> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <properties colspan="2" rowspan="3" valign="top"/> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-bottom-color="#2018A7" border-bottom-style="solid" border-bottom-width="thin"/> <children> <text fixtext="Subscriber Type"> <styles font-family="Tahoma" font-weight="bold"/> </text> <newline/> <image> <properties border="0"/> <imagesource> <fixtext value="info-15x15.gif"/> </imagesource> </image> <text fixtext=" Information how the subscriber is related to the organization"> <styles font-family="Tahoma"/> </text> <newline/> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:SubscriberType"/> <children> <table> <properties bgcolor="#F8DC89" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Subscriber Type Code"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-bottom-color="#AAAAAA" border-bottom-style="solid" border-bottom-width="thin" border-left-color="#AAAAAA" border-left-style="solid" border-left-width="thin" border-right-color="#AAAAAA" border-right-style="solid" border-right-width="thin" border-top-color="#AAAAAA" border-top-style="solid" border-top-width="thin"/> <children> <template> <match match="n1:SubscriberTypeCode"/> <children> <select ownvalue="1"> <styles font-family="Tahoma"/> <properties size="0"/> <selectoption description="Employment" value="Employment"/> <selectoption description="Survivorship" value="Survivorship"/> <selectoption description="Dependent-only Coverage" value="Dependent-only Coverage"/> </select> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Start Date"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-bottom-color="#AAAAAA" border-bottom-style="solid" border-bottom-width="thin" border-left-color="#AAAAAA" border-left-style="solid" border-left-width="thin" border-right-color="#AAAAAA" border-right-style="solid" border-right-width="thin" border-top-color="#AAAAAA" border-top-style="solid" border-top-width="thin"/> <properties width="422"/> <children> <template> <match match="n1:StartDate"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-bottom-color="#2018A7" border-bottom-style="solid" border-bottom-width="thin"/> <children> <text fixtext="Originating Subscriber Type"> <styles font-family="Tahoma" font-weight="bold"/> </text> <newline/> <image> <styles font-family="Tahoma"/> <properties border="0"/> <imagesource> <fixtext value="info-15x15.gif"/> </imagesource> </image> <text fixtext=" Assoicatiated subscriber individual related to this subscriber in the caase of dependency or suviviorship. It contains two parts, one being identifcation data "IdentificationCode" and the individual's name "PersonName""> <styles font-family="Tahoma"/> </text> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:OriginatingSubscriberData"/> <children> <newline/> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="354"/> <children> <text fixtext=" "> <styles font-family="Tahoma"/> </text> <template> <match match="n1:IdentificationCode"/> <children> <template> <match match="n1:IdValue"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </template> </children> </tablecol> <tablecol> <properties align="right" width="200"/> <children> <template> <match match="n1:IdentificationCode"/> <children> <template> <match match="n1:IdValue"/> <children> <text fixtext="Name"> <styles font-family="Tahoma"/> </text> <template> <match match="@name"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="25"/> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <text fixtext=" "> <styles font-family="Tahoma"/> </text> <template> <match match="n1:IdentificationCode"/> <children> <template> <match match="@validTo"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </template> </children> </tablecol> <tablecol/> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:IdentificationCode"/> <children> <template> <match match="@validFrom"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </template> </children> </tablecol> <tablecol/> </children> </tablerow> <tablerow> <children> <tablecol> <properties align="left" colspan="2" valign="top" width="25"/> <children> <text fixtext="Valid to"> <styles font-family="Tahoma" font-size="smaller"/> </text> </children> </tablecol> <tablecol> <properties align="left" colspan="2" valign="top"/> <children> <text fixtext="Valid from"> <styles font-family="Tahoma" font-size="smaller"/> </text> </children> </tablecol> <tablecol/> </children> </tablerow> </children> </tablebody> </children> </table> <table> <styles font-family="Tahoma"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="ID owner"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:IdentificationCode"/> <children> <template> <match match="@idOwner"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <xpath> <styles font-family="Tahoma"/> <match match="n1:PersonName"/> </xpath> </children> </template> <newline/> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-bottom-color="#2018A7" border-bottom-style="solid" border-bottom-width="thin"/> <children> <text fixtext="Person "> <styles font-family="Tahoma" font-weight="bold"/> </text> <newline/> <image> <styles font-family="Tahoma"/> <properties border="0"/> <imagesource> <fixtext value="info-15x15.gif"/> </imagesource> </image> <text fixtext=" Contains data collected on the individual "> <styles font-family="Tahoma"/> </text> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:Person"/> <children> <table> <properties bgcolor="#F8DC89" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties height="276"/> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties height="266" valign="top"/> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Date Of Birth"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="272"/> <children> <template> <match match="n1:DateOfBirth"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Date of Death"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="273"/> <children> <template> <match match="n1:DateOfDeath"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Prior Incorrect Gender"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="270"/> <children> <template> <match match="n1:PriorIncorrectGender"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Prior Incorrect Date of Birth"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:PriorIncorrectDateOfBirth"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties colspan="3" width="170"/> <children> <text fixtext="Disability"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties colspan="2"/> <children> <template> <match match="n1:Disability"/> <children> <template> <match match="n1:DisabilityType"/> <children> <select ownvalue="1"> <properties size="0"/> <selectoption description="Short Term Disability" value="Short Term Disability"/> <selectoption description="Long Term Disability" value="Long Term Disability"/> <selectoption description="Permanent or Total Disability" value="Permanent or Total Disability"/> <selectoption description="No Disability" value="No Disability"/> </select> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <properties align="left" colspan="5" height="48" width="170"/> <children> <template> <match match="n1:Disability"/> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="25"/> </tablecol> <tablecol> <properties align="left" width="213"/> <children> <text fixtext="Disability Start Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="311"/> <children> <template> <match match="n1:StartDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> <tablecol> <properties height="266" valign="top"/> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Gender"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles 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</children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Tobacco user"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-bottom-color="#AAAAAA" border-bottom-style="solid" border-bottom-width="thin" border-left-color="#AAAAAA" border-left-style="solid" border-left-width="thin" border-right-color="#AAAAAA" border-right-style="solid" border-right-width="thin" border-top-color="#AAAAAA" border-top-style="solid" border-top-width="thin"/> <children> <template> <match match="n1:TobaccoUser"/> <children> <checkbox ownvalue="1" checkedvalue="true"> <styles font-family="Tahoma"/> <properties type="checkbox"/> </checkbox> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> 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description="Children Only" value="Children Only"/> <selectoption description="Dependents Only" value="Dependents Only"/> <selectoption description="Employee and Children" value="Employee and Children"/> <selectoption description="Employee and Five or More Dependents" value="Employee and Five or More Dependents"/> <selectoption description="Employee and Four or More Dependents" value="Employee and Four or More Dependents"/> <selectoption description="Employee and One Dependent" value="Employee and One Dependent"/> <selectoption description="Employee and One or More Dependents" value="Employee and One or More Dependents"/> <selectoption description="Employee and Spouse" value="Employee and Spouse"/> <selectoption description="Employee and Three Dependents" value="Employee and Three Dependents"/> <selectoption description="Employee and Three or More Dependents" value="Employee and Three or More Dependents"/> <selectoption description="Employee and Two Dependents" value="Employee and Two Dependents"/> <selectoption description="Employee and Two or More Dependents" value="Employee and Two or More Dependents"/> <selectoption description="Employee Only" value="Employee Only"/> <selectoption description="Family" value="Family"/> <selectoption description="Individual" value="Individual"/> <selectoption description="Not Applicable" value="Not Applicable"/> <selectoption description="Spouse and Children" value="Spouse and Children"/> <selectoption description="Spouse Only" value="Spouse Only"/> <selectoption description="Two Party" value="Two Party"/> </select> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="204"/> <children> <text fixtext="Start Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="358"/> <children> <text fixtext=" "/> <template> <match match="n1:StartDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> <template> <match match="n1:COBRAInformation"/> <children> <table> <properties bgcolor="#F8DC89" border="1" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <text fixtext="COBRA Information"> <styles font-weight="bold"/> </text> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="192"/> <children> <text fixtext="COBRA Start Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="292"/> <children> <template> <match match="n1:COBRAStartDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="189"/> <children> <text fixtext="COBRA End Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="294"/> <children> <template> <match match="n1:COBRAEndDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="189"/> <children> <text fixtext="Paid Through Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="291"/> <children> <template> <match match="n1:PaidThroughDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="192"/> <children> <text fixtext="Qualifying Event Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="294"/> <children> <template> <match match="n1:QualifyingEventDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="194"/> <children> <text fixtext="Qualifying Event Code"/> </children> </tablecol> <tablecol> <children> <template> <match match="n1:QualifyingEventCode"/> <children> <select ownvalue="1"> <properties size="0"/> <selectoption description="Bankruptcy of a Retired Employee" value="Bankruptcy of a Retired Employee"/> <selectoption description="Death" value="Death"/> <selectoption description="Divorce" value="Divorce"/> <selectoption description="Ineligible Child" value="Ineligible Child"/> <selectoption description="Medicare" value="Medicare"/> <selectoption description="Reduction of work hours" value="Reduction of work hours"/> <selectoption description="Separation" value="Separation"/> <selectoption description="Termination of Employment" value="Termination of Employment"/> </select> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> <template> <match match="n1:SpendingAccountCoverage"/> <children> <table> <properties border="1" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties valign="top" width="73"/> <children> <text fixtext="Spending Account Coverage"/> </children> </tablecol> <tablecol> <properties bgcolor="#F8DC89" valign="top"/> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="253"/> <children> <text fixtext="Spending Account Type"/> </children> </tablecol> <tablecol> <children> <template> <match match="@type"/> <children> <select ownvalue="1"> <properties size="0"/> <selectoption description="FSA Health Care" value="FSA Health Care"/> <selectoption description="FSA Dependent Care" value="FSA Dependent Care"/> </select> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="252"/> <children> <text fixtext="Transaction Code"/> </children> </tablecol> <tablecol> <children> <template> <match match="n1:TransactionCode"/> <children> <select ownvalue="1"> <properties size="0"/> <selectoption description="Add" value="Add"/> <selectoption description="Audit" value="Audit"/> <selectoption description="Change" value="Change"/> <selectoption description="Correction" value="Correction"/> <selectoption description="Delete" value="Delete"/> <selectoption description="Employee Information Not Available" value="Employee Information Not Available"/> <selectoption description="Reinstatement" value="Reinstatement"/> <selectoption description="Termination" value="Termination"/> </select> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="253"/> <children> <text fixtext="Start Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="249"/> <children> <template> <match match="n1:StartDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="253"/> <children> <text fixtext="End Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="254"/> <children> <template> <match match="n1:EndDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="253"/> <children> <text fixtext="Plan Year"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="250"/> <children> <template> <match match="n1:PlanYear"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="254"/> <children> <text fixtext="Group Number"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="247"/> <children> <template> <match match="n1:GroupNumber"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="254"/> <children> <text fixtext="Plan Participation Suspention Date "/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="252"/> <children> <template> <match match="n1:PlanParticipationSuspensionDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties valign="top" width="257"/> <children> <text fixtext="Rollover Balance"/> </children> </tablecol> <tablecol> <properties width="251"/> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:RolloverBalance"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <properties valign="top"/> <children> <template> <match match="n1:RolloverBalance"/> <children> <text fixtext="Currency"> <styles font-size="smaller" vertical-align="super"/> </text> <template> <match match="@currency"/> <children> <xpath allchildren="1"> <styles font-size="smaller" vertical-align="super"/> </xpath> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <properties width="73"/> </tablecol> <tablecol> <children> <template> <match match="n1:Carrier"/> <children> <table> <properties bgcolor="#F8DC89" border="1" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <text fixtext="Carrier"> <styles font-weight="bold"/> </text> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties align="left" valign="top" width="170"/> <children> <text fixtext="Identification Code"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="354"/> <children> <text fixtext=" "> <styles font-family="Tahoma"/> </text> <template> <match match="n1:IdentificationCode"/> <children> <template> <match match="n1:IdValue"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </template> </children> </tablecol> <tablecol> <properties align="right" width="200"/> <children> <template> <match match="n1:IdentificationCode"/> <children> <template> <match match="n1:IdValue"/> <children> <text fixtext="Name of ID "> <styles font-family="Tahoma"/> </text> </children> </template> </children> </template> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties align="center" width="200"/> <children> <template> <match match="n1:IdentificationCode"/> <children> <template> <match match="n1:IdValue"/> <children> <template> <match match="@name"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="25"/> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <text fixtext=" "> <styles font-family="Tahoma"/> </text> <template> <match match="n1:IdentificationCode"/> <children> <template> <match match="@validTo"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </template> </children> </tablecol> <tablecol/> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:IdentificationCode"/> <children> <template> <match match="@validFrom"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </template> </children> </tablecol> <tablecol/> </children> </tablerow> <tablerow> <children> <tablecol> <properties align="left" colspan="2" valign="top" width="25"/> <children> <text fixtext="Valid to"> <styles font-family="Tahoma" font-size="smaller"/> </text> </children> </tablecol> <tablecol> <properties align="left" colspan="2" valign="top"/> <children> <text fixtext="Valid from"> <styles font-family="Tahoma" font-size="smaller"/> </text> </children> </tablecol> <tablecol/> </children> </tablerow> </children> </tablebody> </children> </table> <table> <styles font-family="Tahoma"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="ID owner"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:IdentificationCode"/> <children> <template> <match match="@idOwner"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <newline/> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="250"/> <children> <text fixtext="Organization Name "/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <text fixtext=" "/> <template> <match match="n1:OrganizationName"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Contact Use"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="347"/> <children> <template> <match match="n1:ContactInformation"/> <children> <template> <match match="n1:Use"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Location"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="360"/> <children> <template> <match match="n1:ContactInformation"/> <children> <template> <match match="n1:Location"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="When Available"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="430"/> <children> <text fixtext=" "/> <template> <match match="n1:ContactInformation"/> <children> <template> <match match="n1:WhenAvailable"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:ContactInformation"/> <children> <template> <match match="n1:WhenAvailable"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </tablecol> <tablecol> <properties valign="top"/> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Email Address"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <text fixtext=" "/> <template> <match match="n1:ContactInformation"/> <children> <template> <match match="n1:InternetEmailAddress"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Web Address"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <text fixtext=" "/> <template> <match match="n1:ContactInformation"/> <children> <template> <match match="n1:InternetWebAddress"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:ContactInformation"/> <children> <xpath restofcontents="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> <template> <match match="n1:DirectDepositData"/> <children> <table> <properties bgcolor="#F8DC89" border="1" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <text fixtext="Direct Deposit Data"> <styles font-weight="bold"/> </text> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="180"/> <children> <text fixtext="Account Type"/> </children> </tablecol> <tablecol> <children> <template> <match match="n1:AccountType"/> <children> <select ownvalue="1"> <properties size="0"/> <selectoption description="Checking" value="Checking"/> <selectoption description="Savings" value="Savings"/> </select> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties height="23" width="183"/> <children> <text fixtext="Bank Account Number"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties height="23" width="213"/> <children> <template> <match match="n1:BankAccountNumber"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="185"/> <children> <text fixtext="ABA Routing Number"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="209"/> <children> <template> <match match="n1:ABARoutingNumber"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> <template> <match match="n1:ContributionData"/> <children> <table> <properties bgcolor="#F8DC89" border="1" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <text fixtext="Contribution Data"> <styles font-weight="bold"/> </text> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="200"/> <children> <text fixtext="Contributor"/> </children> </tablecol> <tablecol> <children> <template> <match match="@contributor"/> <children> <select ownvalue="1"> <properties size="0"/> <selectoption description="Employer" value="Employer"/> <selectoption description="Employee" value="Employee"/> </select> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties valign="top" width="195"/> <children> <text fixtext="Goal Amount "/> </children> </tablecol> <tablecol> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:GoalAmount"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <children> <template> <match match="n1:GoalAmount"/> <children> <text fixtext="Currency"> <styles font-size="smaller" vertical-align="super"/> </text> <template> <match match="@currency"/> <children> <xpath allchildren="1"> <styles font-size="smaller" vertical-align="super"/> </xpath> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties valign="top" width="195"/> <children> <text fixtext="Amount Per Pay Period"/> </children> </tablecol> <tablecol> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:PerPayPeriodAmount"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <children> <template> <match match="n1:PerPayPeriodAmount"/> <children> <text fixtext="Currency"> <styles font-size="smaller" vertical-align="super"/> </text> <template> <match match="@currency"/> <children> <xpath allchildren="1"> <styles font-size="smaller" vertical-align="super"/> </xpath> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties valign="top" width="196"/> <children> <text fixtext="Year To date Contributions"/> </children> </tablecol> <tablecol> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:YTDContributionAmount"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <children> <template> <match match="n1:YTDContributionAmount"/> <children> <text fixtext="Currency"> <styles font-size="smaller" vertical-align="super"/> </text> <template> <match match="@currency"/> <children> <xpath allchildren="1"> <styles font-size="smaller" vertical-align="super"/> </xpath> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> <template> <match match="n1:RateBasedCoverage"/> <children> <table> <properties border="1" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties valign="top" width="75"/> <children> <text fixtext="Rate Based Coverage"/> </children> </tablecol> <tablecol> <properties bgcolor="#F8DC89" valign="top"/> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="189"/> <children> <text fixtext="Start Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="232"/> <children> <template> <match match="n1:StartDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="188"/> <children> <text fixtext="End Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="230"/> <children> <template> <match match="n1:EndDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="187"/> <children> <text fixtext="Group Number"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="233"/> <children> <template> <match match="n1:GroupNumber"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="184"/> <children> <text fixtext="Transaction Code"/> </children> </tablecol> <tablecol> <properties width="229"/> <children> <template> <match match="n1:TransactionCode"/> <children> <select ownvalue="1"> <properties size="0"/> <selectoption description="Add" value="Add"/> <selectoption description="Audit" value="Audit"/> <selectoption description="Change" value="Change"/> <selectoption description="Correction" value="Correction"/> <selectoption description="Delete" value="Delete"/> <selectoption description="Employee Information Not Available" value="Employee Information Not Available"/> <selectoption description="Reinstatement" value="Reinstatement"/> <selectoption description="Termination" value="Termination"/> </select> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="188"/> <children> <text fixtext="Elected Plan Code"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="225"/> <children> <template> <match match="n1:ElectedPlanCode"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="188"/> <children> <text fixtext="Eligibility Postal Code"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="225"/> <children> <template> <match match="n1:EligibilityPostalCode"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="186"/> <children> <text fixtext="EOI on file with Employer"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="229"/> <children> <template> <match match="n1:EOIOnFileWithEmployer"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="188"/> <children> <text fixtext="EOI Required"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="225"/> <children> <template> <match match="n1:EOIRequired"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <properties width="75"/> </tablecol> <tablecol> <children> <template> <match match="n1:CoverageType"/> <children> <table> <properties bgcolor="#F8DC89" border="1" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <text fixtext="Coverage Type"> <styles font-weight="bold"/> </text> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="188"/> <children> <text fixtext="Product"/> </children> </tablecol> <tablecol> <children> <template> <match match="n1:Product"/> <children> <select ownvalue="1"> <properties size="0"/> <selectoption description="Life Insurance" value="Life Insurance"/> <selectoption description="Accidental Death and Dismemberment Insurance" value="Accidental Death and Dismemberment Insurance"/> <selectoption description="Long-Term Disability Insurance" value="Long-Term Disability Insurance"/> <selectoption description="Short-Term Disability Insurance" value="Short-Term Disability Insurance"/> </select> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties height="25" width="185"/> <children> <text fixtext="Product Type"/> </children> </tablecol> <tablecol> <properties height="25"/> <children> <template> <match match="n1:ProductType"/> <children> <select ownvalue="1"> <properties size="0"/> <selectoption description="Not Applicable" value="Not Applicable"/> <selectoption description="Supplemental" value="Supplemental"/> <selectoption description="Basic" value="Basic"/> <selectoption description="Group" value="Group"/> </select> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="185"/> <children> <text fixtext="Covered Entity"/> </children> </tablecol> <tablecol> <children> <template> <match match="n1:CoveredEntity"/> <children> <select ownvalue="1"> <properties size="0"/> <selectoption description="Self" value="Self"/> <selectoption description="Spouse" value="Spouse"/> <selectoption description="Common Law Spouse" value="Common Law Spouse"/> <selectoption description="Dependent" value="Dependent"/> <selectoption description="Child" value="Child"/> </select> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> <template> <match match="n1:CoverageLevel"/> <children> <table> <properties bgcolor="#F8DC89" border="1" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <text fixtext="Coverage Level"> <styles font-weight="bold"/> </text> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="149"/> <children> <text fixtext="Start Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="281"/> <children> <template> <match match="n1:StartDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <properties border="1" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-bottom-color="#A1B2C3" border-bottom-style="solid" border-bottom-width="thin"/> <children> <text fixtext="Requested Coverage"/> </children> </tablecol> <tablecol> <styles border-bottom-color="#A1B2C3" border-bottom-style="solid" border-bottom-width="thin"/> <children> <text fixtext="Approved Coverage"/> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <children> <template> <match match="n1:RequestedCoverage"/> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties valign="top" width="121"/> <children> <text fixtext="Volume"/> </children> </tablecol> <tablecol> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:Volume"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <children> <template> <match match="n1:Volume"/> <children> <text fixtext="Currency"> <styles font-size="smaller" vertical-align="super"/> </text> <template> <match match="@currency"/> <children> <xpath allchildren="1"> <styles font-size="smaller" vertical-align="super"/> </xpath> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="210"/> <children> <text fixtext="Coverage Level Type"/> </children> </tablecol> <tablecol> <children> <template> <match match="n1:Level"/> <children> <template> <match match="n1:CoverageLevelType"/> <children> <select ownvalue="1"> <properties size="0"/> <selectoption description="Salary" value="Salary"/> <selectoption description="YearsOfService" value="YearsOfService"/> <selectoption description="Fixed" value="Fixed"/> </select> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="210"/> <children> <text fixtext="Coverage Level Multiplier"/> </children> </tablecol> <tablecol> <properties width="140"/> <children> <template> <match match="n1:Level"/> <children> <template> <match match="n1:CoverageLevelMultiplier"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="210"/> <children> <text fixtext="Coverage Value"/> </children> </tablecol> <tablecol> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:Level"/> <children> <template> <match match="n1:CoverageLevelValue"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <children> <template> <match match="n1:Level"/> <children> <template> <match match="n1:CoverageLevelValue"/> <children> <text fixtext="Currency"> <styles font-size="smaller" vertical-align="super"/> </text> <template> <match match="@currency"/> <children> <xpath allchildren="1"> <styles font-size="smaller" vertical-align="super"/> </xpath> </children> </template> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> </children> </tablecol> <tablecol> <children> <template> <match match="n1:ApprovedCoverage"/> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties valign="top" width="121"/> <children> <text fixtext="Volume"/> </children> </tablecol> <tablecol> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:Volume"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <children> <template> <match match="n1:Volume"/> <children> <text fixtext="Currency"> <styles font-size="smaller" vertical-align="super"/> </text> <template> <match match="@currency"/> <children> <xpath allchildren="1"> <styles font-size="smaller" vertical-align="super"/> </xpath> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="210"/> <children> <text fixtext="Coverage Level Type"/> </children> </tablecol> <tablecol> <children> <template> <match match="n1:Level"/> <children> <template> <match match="n1:CoverageLevelType"/> <children> <select ownvalue="1"> <properties size="0"/> <selectoption description="Salary" value="Salary"/> <selectoption description="YearsOfService" value="YearsOfService"/> <selectoption description="Fixed" value="Fixed"/> </select> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="210"/> <children> <text fixtext="Coverage Level Multiplier"/> </children> </tablecol> <tablecol> <properties width="140"/> <children> <template> <match match="n1:Level"/> <children> <template> <match match="n1:CoverageLevelMultiplier"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="210"/> <children> <text fixtext="Coverage Value"/> </children> </tablecol> <tablecol> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:Level"/> <children> <template> <match match="n1:CoverageLevelValue"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <children> <template> <match match="n1:Level"/> <children> <template> <match match="n1:CoverageLevelValue"/> <children> <text fixtext="Currency"> <styles font-size="smaller" vertical-align="super"/> </text> <template> <match match="@currency"/> <children> <xpath allchildren="1"> <styles font-size="smaller" vertical-align="super"/> </xpath> </children> </template> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> <template> <match match="n1:Carrier"/> <children> <table> <properties bgcolor="#F8DC89" border="1" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <text fixtext="Carrier"> <styles font-weight="bold"/> </text> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties align="left" valign="top" width="170"/> <children> <text fixtext="Identification Code"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="354"/> <children> <text fixtext=" "> <styles font-family="Tahoma"/> </text> <template> <match match="n1:IdentificationCode"/> <children> <template> <match match="n1:IdValue"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </template> </children> </tablecol> <tablecol> <properties align="right" width="200"/> <children> <template> <match match="n1:IdentificationCode"/> <children> <template> <match match="n1:IdValue"/> <children> <text fixtext="Name of ID "> <styles font-family="Tahoma"/> </text> </children> </template> </children> </template> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties align="center" width="200"/> <children> <template> <match match="n1:IdentificationCode"/> <children> <template> <match match="n1:IdValue"/> <children> <template> <match match="@name"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="25"/> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <text fixtext=" "> <styles font-family="Tahoma"/> </text> <template> <match match="n1:IdentificationCode"/> <children> <template> <match match="@validTo"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </template> </children> </tablecol> <tablecol/> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:IdentificationCode"/> <children> <template> <match match="@validFrom"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </template> </children> </tablecol> <tablecol/> </children> </tablerow> <tablerow> <children> <tablecol> <properties align="left" colspan="2" valign="top" width="25"/> <children> <text fixtext="Valid to"> <styles font-family="Tahoma" font-size="smaller"/> </text> </children> </tablecol> <tablecol> <properties align="left" colspan="2" valign="top"/> <children> <text fixtext="Valid from"> <styles font-family="Tahoma" font-size="smaller"/> </text> </children> </tablecol> <tablecol/> </children> </tablerow> </children> </tablebody> </children> </table> <table> <styles font-family="Tahoma"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="ID owner"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:IdentificationCode"/> <children> <template> <match match="@idOwner"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <newline/> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="250"/> <children> <text fixtext="Organization Name "/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <text fixtext=" "/> <template> <match match="n1:OrganizationName"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Contact Use"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="347"/> <children> <template> <match match="n1:ContactInformation"/> <children> <template> <match match="n1:Use"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Location"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="360"/> <children> <template> <match match="n1:ContactInformation"/> <children> <template> <match match="n1:Location"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="When Available"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="430"/> <children> <text fixtext=" "/> <template> <match match="n1:ContactInformation"/> <children> <template> <match match="n1:WhenAvailable"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:ContactInformation"/> <children> <template> <match match="n1:WhenAvailable"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </tablecol> <tablecol> <properties valign="top"/> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Email Address"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <text fixtext=" "/> <template> <match match="n1:ContactInformation"/> <children> <template> <match match="n1:InternetEmailAddress"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Web Address"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <text fixtext=" "/> <template> <match match="n1:ContactInformation"/> <children> <template> <match match="n1:InternetWebAddress"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:ContactInformation"/> <children> <xpath restofcontents="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> <template> <match match="n1:BeneficiaryData"/> <children> <xpath allchildren="1"/> </children> </template> <template> <match match="n1:Question"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> </children> </template> <newline/> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-bottom-color="#2018A7" border-bottom-style="solid" border-bottom-width="thin"/> <children> <text fixtext="Employment"> <styles font-family="Tahoma" font-weight="bold"/> </text> <newline/> <image> <properties border="0"/> <imagesource> <fixtext value="info-15x15.gif"/> </imagesource> </image> <text fixtext=" This section is used to contain information about the individual subscriber's employment data. Information contained could be current employment status, organization, dates assoicated with hiring or firing. "/> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:Employment"/> <children> <table> <properties bgcolor="#F8DC89" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Employee ID"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="244"/> <children> <template> <match match="@employeeId"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="EEOC Code"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="224"/> <children> <template> <match match="n1:EEOCCode"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="VIP Flag"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="205"/> <children> <template> <match match="n1:VIPFlag"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Hire Date "/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="192"/> <children> <template> <match match="n1:HireDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Original Hire Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="256"/> <children> <template> <match match="n1:OriginalHireDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <newline/> </children> </tablecol> <tablecol> <properties valign="top"/> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="243"/> <children> <text fixtext="Employement Termination Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:EmploymentTerminationDate"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Return To Work Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:ReturnToWorkDate"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Last Day Worked"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:LastDayWorked"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:EmploymentLevel"/> <children> <table> <properties border="1" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties valign="top"/> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties valign="top" width="149"/> <children> <text fixtext="Employment Level"/> </children> </tablecol> <tablecol> <properties valign="top"/> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="263"/> <children> <text fixtext="Employment Level Code"/> </children> </tablecol> <tablecol> <children> <template> <match match="n1:EmploymentLevelCode"/> <children> <select ownvalue="1"> <properties size="0"/> <selectoption description="Full Time" value="Full Time"/> <selectoption description="Part Time" value="Part Time"/> </select> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="265"/> <children> <text fixtext="Start Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="296"/> <children> <template> <match match="n1:StartDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <properties width="149"/> </tablecol> <tablecol/> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> <template> <match match="n1:EmploymentStatus"/> <children> <table> <properties border="1" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties valign="top"/> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties valign="top" width="145"/> <children> <text fixtext="Employment Status"/> </children> </tablecol> <tablecol> <properties rowspan="2" valign="top"/> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="271"/> <children> <text fixtext="Employment Status Code"/> </children> </tablecol> <tablecol> <children> <template> <match match="n1:EmploymentStatusCode"/> <children> <select ownvalue="1"> <properties size="0"/> <selectoption description="Active Foreign Military" value="Active Foreign Military"/> <selectoption description="Active Domestic Military" value="Active Domestic Military"/> <selectoption description="Active" value="Active"/> <selectoption description="Leave of Absence" value="Leave of Absence"/> <selectoption description="Short Term Disability" value="Short Term Disability"/> <selectoption description="Long Term Disability" value="Long Term Disability"/> <selectoption description="Retired" value="Retired"/> <selectoption description="Terminated" value="Terminated"/> </select> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="272"/> <children> <text fixtext="Start Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="290"/> <children> <template> <match match="n1:StartDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <properties width="145"/> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> <template> <match match="n1:EmploymentOrganization"/> <children> <table> <properties border="1" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties height="162" valign="top"/> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties valign="top" width="121"/> <children> <text fixtext="Employment Organization"/> </children> </tablecol> <tablecol> <properties rowspan="2" valign="top"/> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="287"/> <children> <text fixtext="Employment Organization Group"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="296"/> <children> <template> <match match="n1:EmploymentOrganizationGroup"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="287"/> <children> <text fixtext="Employment Organization Group Type"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="296"/> <children> <template> <match match="n1:EmploymentOrganizationGroupType"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="290"/> <children> <text fixtext="Start Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="296"/> <children> <template> <match match="n1:StartDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <properties width="121"/> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> </children> </template> <newline/> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-bottom-color="#2018A7" border-bottom-style="solid" border-bottom-width="thin"/> <children> <text fixtext="HIPAA"> <styles font-family="Tahoma" font-weight="bold"/> </text> <newline/> <image> <properties border="0"/> <imagesource> <fixtext value="info-15x15.gif"/> </imagesource> </image> <text fixtext=" Information for fulfilling Health Insurance Portability and Accountability Act ."/> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:HIPAA"/> <children> <table> <properties bgcolor="#F8DC89" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Prior Coverage Months "/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <text fixtext=" "/> <template> <match match="n1:PriorCoverageMonths"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-bottom-color="#2018A7" border-bottom-style="solid" border-bottom-width="thin"/> <children> <text fixtext="Medicare"> <styles font-family="Tahoma" font-weight="bold"/> </text> <newline/> <image> <properties border="0"/> <imagesource> <fixtext value="info-15x15.gif"/> </imagesource> </image> <text fixtext=" The field used for entering information about previous or current medicare coverage."/> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:Medicare"/> <children> <table> <properties bgcolor="#F8DC89" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Start Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="208"/> <children> <text fixtext=" "/> <template> <match match="n1:StartDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="End Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="208"/> <children> <text fixtext=" "/> <template> <match match="n1:EndDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Medicare Part A Number"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:MedicarePartANumber"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Medicare Part B Number"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:MedicarePartBNumber"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> <newline/> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-bottom-color="#2018A7" border-bottom-style="solid" border-bottom-width="thin"/> <children> <text fixtext="Medicaid"> <styles font-family="Tahoma" font-weight="bold"/> </text> <newline/> <image> <properties border="0"/> <imagesource> <fixtext value="info-15x15.gif"/> </imagesource> </image> <text fixtext=" This field is used for entering and storing information about previous or current medicaid coverage."/> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:Medicaid"/> <children> <table> <properties bgcolor="#F8DC89" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Start Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="224"/> <children> <template> <match match="n1:StartDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="End Date "/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="226"/> <children> <template> <match match="n1:EndDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-bottom-color="#2018A7" border-bottom-style="solid" border-bottom-width="thin"/> <children> <text fixtext="Benefit Reporting Information"> <styles font-family="Tahoma" font-weight="bold"/> </text> <newline/> <image> <properties border="0"/> <imagesource> <fixtext value="info-15x15.gif"/> </imagesource> </image> <text fixtext=" This field is used for entering information required for identifying the type of reporting."/> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:BenefitReportingInformation"/> <children> <table> <properties bgcolor="#F8DC89" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Benefit Reporting Type"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:BenefitReportingType"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Benifit Reporting Value"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="289"/> <children> <template> <match match="n1:BenefitReportingValue"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Start Date"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="290"/> <children> <template> <match match="n1:StartDate"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <styles border-bottom-color="#2018A7" border-bottom-style="solid" border-bottom-width="thin"/> <children> <text fixtext="Dependent"> <styles font-family="Tahoma" font-weight="bold"/> </text> <newline/> <image> <properties border="0"/> <imagesource> <fixtext value="info-15x15.gif"/> </imagesource> </image> <text fixtext=" This is an optional field for information on the subscriber's dependent. There can be more than one of these fields, or none at all."/> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:Dependent"/> <children> <table> <properties bgcolor="#F8DC89" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Relationship "/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="@relationshipCode"/> <children> <select ownvalue="1"> <properties size="0"/> <selectoption description="Adopted Child" value="Adopted Child"/> <selectoption description="Brother or Sister" value="Brother or Sister"/> <selectoption description="Brother-in-Law or Sister-in-Law" value="Brother-in-Law or Sister-in-Law"/> <selectoption description="Child" value="Child"/> <selectoption description="Collateral Dependent" value="Collateral Dependent"/> <selectoption description="Court Appointed Guardian" value="Court Appointed Guardian"/> <selectoption description="Cousin" value="Cousin"/> <selectoption description="Dependent of a Minor Dependent" value="Dependent of a Minor Dependent"/> <selectoption description="Ex-Spouse" value="Ex-Spouse"/> <selectoption description="Father" value="Father"/> <selectoption description="Father or Mother" value="Father or Mother"/> <selectoption description="Father-in-Law or Mother-in-Law" value="Father-in-Law or Mother-in-Law"/> <selectoption description="Foster Child" value="Foster Child"/> <selectoption description="Grandfather or Grandmother" value="Grandfather or Grandmother"/> <selectoption description="Grandson or Granddaughter" value="Grandson or Granddaughter"/> <selectoption description="Guardian" value="Guardian"/> <selectoption description="Life Partner" value="Life Partner"/> <selectoption description="Mother" value="Mother"/> <selectoption description="Nephew or Niece" value="Nephew or Niece"/> <selectoption description="Self" value="Self"/> <selectoption description="Son-in-Law or Daughter-in-Law" value="Son-in-Law or Daughter-in-Law"/> <selectoption description="Sponsored Dependent" value="Sponsored Dependent"/> <selectoption description="Spouse" value="Spouse"/> <selectoption description="Stepfather" value="Stepfather"/> <selectoption description="Stepmother" value="Stepmother"/> <selectoption description="Stepson or Stepdaugher" value="Stepson or Stepdaugher"/> <selectoption description="Uncle or Aunt" value="Uncle or Aunt"/> <selectoption description="Ward" value="Ward"/> </select> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Full Time Student "/> </children> 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<properties width="170"/> <children> <text fixtext="When Available"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="430"/> <children> <text fixtext=" "/> <template> <match match="n1:ContactInformation"/> <children> <template> <match match="n1:WhenAvailable"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:ContactInformation"/> <children> <template> <match match="n1:WhenAvailable"/> <children> <xpath allchildren="1"/> </children> </template> </children> </template> </children> </tablecol> <tablecol> <properties valign="top"/> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Email Address"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" 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<children> <template> <match match="@type"/> <children> <select ownvalue="1"> <properties size="0"/> <selectoption description="postOfficeBoxAddress" value="postOfficeBoxAddress"/> <selectoption description="streetAddress" value="streetAddress"/> <selectoption description="militaryAddress" value="militaryAddress"/> <selectoption description="undefined" value="undefined"/> </select> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:DeliveryAddress"/> <children> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="134"/> <children> <text fixtext="Street Address"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="366"/> <children> <template> <match match="n1:AddressLine"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="7"/> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:BuildingNumber"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> <tablecol/> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:StreetName"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> <tablecol/> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:Unit"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <properties align="left" colspan="2" valign="top" width="149"/> <children> <text fixtext="Building Number"> <styles font-size="smaller"/> </text> </children> </tablecol> <tablecol> <properties align="left" colspan="2" valign="top"/> <children> <text fixtext="Street Name"> <styles font-size="smaller"/> </text> </children> </tablecol> <tablecol> <properties align="left" colspan="2" valign="top"/> <children> <text fixtext="Unit Number"> <styles font-size="smaller"/> </text> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Post Office Box: "/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:PostOfficeBox"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> 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</template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Region"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="238"/> <children> <template> <match match="n1:Region"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Municipality"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="240"/> <children> <template> <match match="n1:Municipality"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <template> <match match="n1:Recipient"/> <children> <table> <properties border="1" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <children> <text fixtext="Recipient"/> <xpath> <match match="n1:PersonName"/> </xpath> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Organization "/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="280"/> <children> <template> <match match="n1:Organization"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="170"/> <children> <text fixtext="Organization Name"/> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties width="285"/> <children> <template> <match match="n1:OrganizationName"/> <children> <xpath allchildren="1"/> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <properties border="1"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties valign="top" width="123"/> <children> <text fixtext="Additional Text"/> </children> </tablecol> <tablecol> <children> <template> <match match="n1:AdditionalText"/> <children> <multilinefield ownvalue="1"> <properties cols="34" rows="4" value=""/> </multilinefield> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> <template> <match match="n1:TTYTDD"/> <children> <table> <properties border="1" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties align="left"/> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="41"/> <children> <text fixtext="TTY/TDD"/> </children> </tablecol> <tablecol> <properties width="16"/> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:InternationalCountryCode"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> <tablecol> <properties width="18"/> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:NationalNumber"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> <tablecol/> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:AreaCityCode"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> <tablecol/> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:SubscriberNumber"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> <tablecol/> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:Extension"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <properties width="41"/> </tablecol> <tablecol> <properties colspan="2" valign="top" width="10"/> <children> <text fixtext="International"> <styles font-family="Tahoma" font-size="smaller"/> </text> </children> </tablecol> <tablecol> <properties colspan="2" valign="top" width="18"/> <children> <text fixtext="National"> <styles font-family="Tahoma" font-size="smaller"/> </text> </children> </tablecol> <tablecol> <properties colspan="2" valign="top"/> <children> <text fixtext="Area Code"> <styles font-family="Tahoma" font-size="smaller"/> </text> </children> </tablecol> <tablecol> <properties colspan="2" valign="top"/> <children> <text fixtext="Number"> <styles font-family="Tahoma" font-size="smaller"/> </text> </children> </tablecol> <tablecol> <properties colspan="2" valign="top"/> <children> <text fixtext="Extention"> <styles font-family="Tahoma" font-size="smaller"/> </text> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties height="29"/> <children> <text fixtext="Formatted Number"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties height="29" width="485"/> <children> <template> <match match="n1:FormattedNumber"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> <template> <match match="n1:Telephone"/> <children> <table> <properties border="1" width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties align="left"/> <children> <table> <properties width="100%"/> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties width="41"/> <children> <text fixtext="Telephone"/> </children> </tablecol> <tablecol> <properties width="16"/> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:InternationalCountryCode"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> <tablecol> <properties width="18"/> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:NationalNumber"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> <tablecol/> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:AreaCityCode"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> <tablecol/> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:SubscriberNumber"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> <tablecol/> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <children> <template> <match match="n1:Extension"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> </children> </tablerow> <tablerow> <children> <tablecol> <properties width="41"/> </tablecol> <tablecol> <properties colspan="2" valign="top" width="10"/> <children> <text fixtext="International"> <styles font-family="Tahoma" font-size="smaller"/> </text> </children> </tablecol> <tablecol> <properties colspan="2" valign="top" width="18"/> <children> <text fixtext="National"> <styles font-family="Tahoma" font-size="smaller"/> </text> </children> </tablecol> <tablecol> <properties colspan="2" valign="top"/> <children> <text fixtext="Area Code"> <styles font-family="Tahoma" font-size="smaller"/> </text> </children> </tablecol> <tablecol> <properties colspan="2" valign="top"/> <children> <text fixtext="Number"> <styles font-family="Tahoma" font-size="smaller"/> </text> </children> </tablecol> <tablecol> <properties colspan="2" valign="top"/> <children> <text fixtext="Extention"> <styles font-family="Tahoma" font-size="smaller"/> </text> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> <table> <children> <tablebody> <children> <tablerow> <children> <tablecol> <properties height="29"/> <children> <text fixtext="Formatted Number"> <styles font-family="Tahoma"/> </text> </children> </tablecol> <tablecol> <styles border-color="#AAAAAA" border-style="solid" border-width="thin"/> <properties height="29" width="485"/> <children> <template> <match match="n1:FormattedNumber"/> <children> <xpath allchildren="1"> <styles font-family="Tahoma"/> </xpath> </children> </template> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </tablecol> </children> </tablerow> </children> </tablebody> </children> </table> </children> </template> <pagelayout> <properties pagemultiplepages="0" pagenumberingformat="1" pagenumberingstartat="1" paperheight="11in" papermarginbottom="0.79in" papermarginleft="0.8in" papermarginright="0.8in" papermargintop="0.79in" paperwidth="8.5in"/> </pagelayout> </structure> 
