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Appendix B — Sample Data Request Part II <br />Preferred Data Format <br />Kew; <br />EE Type - M = Miscellaneous, P - Policeft.aw, Enforcement; F = Firefighter <br />Current Status (as of the current valuation date) - Active, Temporary, Part-Time, Retired, Surviving Spouse, Retired Disabled <br />Previous Valuation Status (as of the previous OPEB valuation) - Active, Temporary, Part-Time, Retired, Surviving Spouse, Retired Disabled <br />Group- use this column if the agency would like the results broken out Into groups (e.g., Collective Bargaining Units, Management, Board, etc.) <br />DOB - Date of Birth <br />DOH - Date of Hire <br />DOT - Date of Termination <br />DOR - Date of Retirement <br />Total PERS Service - please provide either the employees total PERS service or their original PERS hire date <br />Retirement Formula - ax. 2% at 55 <br />Retiree Benefit % - only fill out if vesting <br />Marital Status - Please mark either 1 (If marred) or 0 (if single) <br />Cov Sp - Please mark if the employee's spouse lakes medical coverage (1 - covered, 0 = not covered) <br />Sp DOB - Spouse Date of Birth <br />Cov Codes - (EE only = 1, EE+ Spouse = 2, EE + Chlld(ren) but no spouse= 3, EE +Spouse +children - 4) <br />Plan - Name of Insurance Provider (e.g. Kaiser HMO, Blue Shield etc. - if employee has waived coverage please mark "Waived ") <br />Ee Paid - the employee paid portion of the medical premium <br />Er Paid - the employer paid portion of the medical premium <br />Note: please fill In columns for benefits retirees can Participate in (even 100% at retiree expense). <br />O <br />Z <br />W <br />W <br />T <br />> <br />c <br />t� <br />> <br />Y>o <br />N <br />o <br />p <br />m <br />O <br />x <br />O <br />aO <br />, <br />G <br />LL ZY t <br />E <br />d NW <br />y <br />'N TC . <br />N W W <br />C <br />N <br />yy <br />0 <br />O <br />W <br />9 <br />U <br />N <br />yy tl <br />a <br />g <br />T <br />a <br />d <br />9 <br />� <br />1O 5 <br />a <br />O <br />ry T <br />0.Y <br />9 <br />9 <br />> <br />G O <br />� <br />= <br />> <br />? <br />_f <br />d G <br />a <br />WO <br />'0 <br />O <br />d <br />IWC <br />B <br />S <br />wW. <br />J <br />O <br />xa p W- <br />W <br />w V W <br />LL <br />