<?xml version="1.0" encoding="UTF-8"?>
<!-- edited with XMLSpy v2006 rel. 3 sp1 (http://www.altova.com) by Chuck Allen (HR-XML Consortium, Inc.) -->
<Enrollment xmlns="http://ns.hr-xml.org/2007-04-15" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://ns.hr-xml.org/2007-04-15 Enrollment.xsd" creationDate="2004-02-04T12:00:00-05:00">
	<Organization organizationName="Information and Emergency">
		<Subscriber>
			<SubscriberType>
				<SubscriberTypeCode>Employment</SubscriberTypeCode>
				<StartDate>2000-03-06</StartDate>
			</SubscriberType>
			<Person>
				<IdentificationCode>
					<IdValue name="SocialSecurityNumber">333111111</IdValue>
				</IdentificationCode>
				<PersonName>
					<GivenName>MAX</GivenName>
					<MiddleName>B</MiddleName>
					<FamilyName>SMART</FamilyName>
				</PersonName>
				<Gender>1</Gender>
				<DateOfBirth>1965-12-10</DateOfBirth>
				<ContactInformation>
					<PostalAddress type="streetAddress">
						<CountryCode>US</CountryCode>
						<PostalCode>80516</PostalCode>
						<Region>CO</Region>
						<Municipality>ERIE</Municipality>
						<DeliveryAddress>
							<AddressLine>86 SOLE ROAD</AddressLine>
						</DeliveryAddress>
					</PostalAddress>
				</ContactInformation>
				<MaritalStatus>
					<MaritalStatusCode>Married</MaritalStatusCode>
					<StartDate>2003-06-01</StartDate>
				</MaritalStatus>
			</Person>
			<Coverage>
				<TierCoverage type="Health">
					<TransactionCode>Change</TransactionCode>
					<ElectedPlanCode>1</ElectedPlanCode>
					<GroupNumber>012345600140014TTRX</GroupNumber>
					<COBRAStatus>non-COBRA</COBRAStatus>
					<StartDate>2003-06-01</StartDate>
					<CoverageLevel>
						<CoverageLevelCode>Family</CoverageLevelCode>
						<StartDate>2003-10-28</StartDate>
					</CoverageLevel>
				</TierCoverage>
			</Coverage>
			<Employment>
				<EmploymentStatus>
					<EmploymentStatusCode>Active</EmploymentStatusCode>
					<StartDate>2000-03-06</StartDate>
				</EmploymentStatus>
				<HireDate>2000-03-06</HireDate>
			</Employment>
			<Dependent relationshipCode="Child" fullTimeStudent="false">
				<Person>
					<IdentificationCode>
						<IdValue name="SocialSecurityNumber">000000000</IdValue>
					</IdentificationCode>
					<PersonName>
						<GivenName>CATHY</GivenName>
						<FamilyName>SMART</FamilyName>
					</PersonName>
					<Gender>2</Gender>
					<DateOfBirth>2003-10-28</DateOfBirth>
					<ContactInformation>
						<PostalAddress type="streetAddress">
							<CountryCode>US</CountryCode>
							<PostalCode>80522</PostalCode>
							<Region>CO</Region>
							<Municipality>Denver</Municipality>
							<DeliveryAddress>
								<AddressLine>503 PINE CIRCLE</AddressLine>
							</DeliveryAddress>
						</PostalAddress>
					</ContactInformation>
				</Person>
				<Coverage>
					<TierCoverage type="Health">
						<TransactionCode>Add</TransactionCode>
						<ElectedPlanCode>1</ElectedPlanCode>
						<GroupNumber>012345600140014TTRX</GroupNumber>
						<COBRAStatus>non-COBRA</COBRAStatus>
						<StartDate>2003-10-28</StartDate>
						<CoverageLevel>
							<CoverageLevelCode>Family</CoverageLevelCode>
							<StartDate>2003-10-28</StartDate>
						</CoverageLevel>
						<EligibilityPostalCode>80516</EligibilityPostalCode>
					</TierCoverage>
				</Coverage>
			</Dependent>
			<Dependent relationshipCode="Child" fullTimeStudent="true">
				<Person>
					<IdentificationCode>
						<IdValue name="SocialSecurityNumber">333331111</IdValue>
					</IdentificationCode>
					<PersonName>
						<GivenName>JONATHAN</GivenName>
						<MiddleName/>
						<FamilyName>SMART</FamilyName>
					</PersonName>
					<Gender>1</Gender>
					<DateOfBirth>1979-12-01</DateOfBirth>
					<ContactInformation>
						<PostalAddress type="streetAddress">
							<CountryCode>US</CountryCode>
							<PostalCode>55812</PostalCode>
							<Region>MN</Region>
							<Municipality>Minneapolis</Municipality>
							<DeliveryAddress>
								<AddressLine>52 COLLEGE DR</AddressLine>
								<AddressLine>APT 202</AddressLine>
							</DeliveryAddress>
						</PostalAddress>
					</ContactInformation>
					<MaritalStatus>
						<MaritalStatusCode>Single</MaritalStatusCode>
						<StartDate>1930-01-01</StartDate>
					</MaritalStatus>
				</Person>
				<Coverage>
					<TierCoverage type="Health">
						<TransactionCode>Change</TransactionCode>
						<ElectedPlanCode>1</ElectedPlanCode>
						<GroupNumber>012345600140014TTRX</GroupNumber>
						<COBRAStatus>non-COBRA</COBRAStatus>
						<StartDate>2003-06-01</StartDate>
						<EndDate>2004-12-02</EndDate>
						<CoverageLevel>
							<CoverageLevelCode>Not Applicable</CoverageLevelCode>
							<StartDate>2003-10-28</StartDate>
						</CoverageLevel>
						<EligibilityPostalCode>80516</EligibilityPostalCode>
					</TierCoverage>
				</Coverage>
			</Dependent>
			<Dependent relationshipCode="Spouse" fullTimeStudent="false">
				<Person>
					<IdentificationCode>
						<IdValue name="SocialSecurityNumber">333221111</IdValue>
					</IdentificationCode>
					<PersonName>
						<GivenName>KIMBERLY</GivenName>
						<MiddleName>M</MiddleName>
						<FamilyName>SMART</FamilyName>
					</PersonName>
					<Gender>2</Gender>
					<DateOfBirth>1963-10-28</DateOfBirth>
					<ContactInformation>
						<PostalAddress type="streetAddress">
							<CountryCode>US</CountryCode>
							<PostalCode>80516</PostalCode>
							<Region>CO</Region>
							<Municipality>ERIE</Municipality>
							<DeliveryAddress>
								<AddressLine>86 SOLE ROAD</AddressLine>
							</DeliveryAddress>
						</PostalAddress>
					</ContactInformation>
					<MaritalStatus>
						<MaritalStatusCode>Married</MaritalStatusCode>
						<StartDate>2003-06-01</StartDate>
					</MaritalStatus>
				</Person>
				<Coverage>
					<TierCoverage type="Health">
						<TransactionCode>Change</TransactionCode>
						<ElectedPlanCode>1</ElectedPlanCode>
						<GroupNumber>012345600140014TTRX</GroupNumber>
						<COBRAStatus>non-COBRA</COBRAStatus>
						<StartDate>2003-06-01</StartDate>
						<CoverageLevel>
							<CoverageLevelCode>Family</CoverageLevelCode>
							<StartDate>2003-10-28</StartDate>
						</CoverageLevel>
					</TierCoverage>
				</Coverage>
			</Dependent>
		</Subscriber>
		<OrganizationId>
			<IdValue>411911</IdValue>
		</OrganizationId>
	</Organization>
</Enrollment>
