identifier: Member Number/?ngen-9?

status: Active

type: Other Private Insurance

policyHolder: Jim Chalmers Male, DoB: 1974-12-25 ( Social Security number (use: usual, period: 2001-05-06 --> (ongoing)))

subscriber: Jim Chalmers Male, DoB: 1974-12-25 ( Social Security number (use: usual, period: 2001-05-06 --> (ongoing)))

subscriberId: 12191

beneficiary: Jim Chalmers Male, DoB: 1974-12-25 ( Social Security number (use: usual, period: 2001-05-06 --> (ongoing)))

dependent: 0

relationship: Self

period: 2011-05-23 --> 2012-05-23

payor: Organization Health Level Seven International

class

type: Group

value: CBI35

name: Corporate Baker's Inc. Local #35

class

type: Plan

value: B37FC

name: Full Coverage: Medical, Dental, Pharmacy, Vision, EHC

order: 9