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Attachment B - Sample Data Request Part II <br />Preferred Data Format <br />A a <br />BE Type <br />M= Miscellaneous, P=Police/Law Enforcement; F = Firefighter <br />Current Status <br />(as of the current valuation data) Active, Temporary, Part-Time,retired, Surviving Spouse, Retired Disabled <br />Previous Valuation Status (as of the previous OPEB valuatlan) Active, Temporary, Par:Jlma, Retired, Surviving Spouse, Retired Disabled <br />Group <br />Use this column if the agency would like the results broken out Into groups(e.g., Collective Bargaining units, Management, Board, etcl <br />DOB <br />Date of Birth <br />DOH <br />Date of Hire <br />DOT <br />Date ofTerminatlon <br />DOR <br />Date of Retlrament <br />Total PERS Service <br />Please provide the employee's total service in PERS. in years/fractlon of years <br />Retirement Formula <br />Example: 2% at 55 <br />%of Full Time <br />If part-time employees can qualify for OPEB, please indicate the 91 of full-time worked (50%, 75%, etc.) <br />Marts(Status <br />Please mark either I(if married) or 0 lif aingle) <br />COVSP <br />Please mark if the employee's spouse takes medical coverage (1 -covered, 0=not covered) <br />Sp DOB <br />Spouse Date of Birth <br />Youngest DEP DOB <br />Youngest covered dependent child's Date of Birth <br />Cov Codes <br />Please complete for each type of coverage(medical, dental, etc.). <br />Use Waived =0, EE only= 1, EE+Spouse -2, EE+Child(ren) but no spouse =3, EE+Spouse +children =4 <br />Plan nate: <br />Please include the Insurer name, type, region and premium rate year (e.g. Kaiser HMO Bay 2015, PERS Choice PPO Sacramento 2015, etc. <br />note: <br />If active employee has waived coverage please mark "ActWaived"; If retiree has waived coverage, please mark "RetWalved") <br />Ea Palo <br />The employee or retiree paid portion of the medical premium <br />Er Pald <br />The employer Palo portion of the medical promlum <br />87 <br />'� <br />me <br />,n <br />9 <br />cg <br />E <br />i <br />a <br />al <br />o <br />o <br />a <br />t? <br />u <br />