{
  "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"
      }
    }
  }
}