Datasets:
Formats:
json
Size:
1K - 10K
Tags:
document-ai
form-understanding
key-information-extraction
layout-analysis
multilingual
structured-prediction
License:
File size: 2,429 Bytes
e87296f | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 | {
"GROUP NUMBER": "482917",
"EMPLOYER/PLANHOLDER NAME": "Acme Manufacturing Inc.",
"PROVIDER NAME（LAST.FIRST.M）": "Johnson, Emily R.",
"SOCIAL SECURITY #/ ITIN": "527-84-1936",
"PROVIDER HOME ADDRESS (STREET, CITY, STATE, ZIP)": "1842 Cedar Ridge Dr, Portland, OR 97205",
"Please Indicate the coverage to which the beneficiary(ies) apply": "AD&D",
"BENEFICIARY INFORMATION": [
{
"Social Security #/ITIN": "638-29-4715",
"Name": "Michael Johnson",
"Date of Birth": "04/18/1986",
"Relationship": "Spouse",
"Phone#": "4155550198",
"Email": "jordan.miller@example.com",
"Address": "2487 Maple Street, San Francisco, CA 94115",
"%": "50%",
"value": "Contingent"
},
{
"Name": "Jordan Miller",
"Social Security #/ITIN": "527-84-1936",
"%": "50%",
"Date of Birth": "07/22/1986",
"Relationship": "Spouse",
"Phone#": "4155550126",
"Email": "casey.miller@example.com",
"Address": "742 Evergreen Terrace, Springfield, IL 62704",
"value": "Contingent"
},
{
"%": "50%",
"Name": "Michael Anderson",
"Relationship": "Spouse",
"Date of Birth": "04/12/1988",
"Social Security #/ITIN": "123-45-6789",
"Email": "michael.anderson@example.com",
"Phone#": "3035550147",
"Address": "118 Pine Street, Denver, CO 80203",
"value": "Primary"
},
{
"%": "50%",
"Name": "Laura Anderson",
"Date of Birth": "04/12/1985",
"Social Security #/ITIN": "123-45-6789",
"Relationship": "Spouse",
"Phone#": "5558675309",
"Email": "jordan.miller@example.com",
"Address": "742 Evergreen Terrace, Springfield, IL 62704",
"value": "Primary"
}
],
"SIGNATURE OF WITNESS (SOMEONE OTHER THAN BENEFICIARY)": "Alex Carter",
"Signature of Provider's Spouse": "Taylor Miller",
"Minors named as beneficiaries": {
"Are any of the Beneficiaries identified above considered a minor in the state in which they reside?": {
"Yes": {
"Custodian to Minor Beneficiaries": {
"Name": "Jordan Miller"
},
"Social Security Number (or FEIN/TIN # if a corporate entity)": "384729156",
"Date of Birth (mm-dd-yyyy) (if an individual)": "07/24/1986",
"Address/City/State/Zip": "1428 Oak Meadow Lane, Denver, CO 80203",
"Phone": "3035554187"
}
}
}
}
|