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Company Name

21

ENROLLMENT WORKSHEET

Medical

Plan 1

Plan 2

Plan 3

Plan 4

Monthly Cost

Employee

$

$

$

$

Employee & Spouse

$

$

$

$

Employee & Child(ren)

$

$

$

$

Family

$

$

$

$

Dental

Plan 1

Plan 2

Plan 3

Plan 4

Monthly Cost

Employee

$

$

$

$

Employee & Spouse

$

$

$

$

Employee & Child(ren)

$

$

$

$

Family

$

$

$

$

Vision

Plan 1

Plan 2

Plan 3

Plan 4

Monthly Cost

Employee

$

$

$

$

Employee & Spouse

$

$

$

$

Employee & Child(ren)

$

$

$

$

Family

$

$

$

$

Health Savings Account (HSA)

Monthly Cost

If participating, what is your monthly contribution?

(Yearly Maximums: Individual $3,350; Family

$6,650 and if you are 55 or older, you can make “catch-up” contributions of an additional $1,000 per

year.)

Medical Flexible Spending Account

Monthly Cost

If participating, what is your monthly contribution?

($2,550 Yearly Maximum)

Limited Flexible Spending Account

(with an HSA)

Monthly Cost

If participating, what is your monthly contribution?

($2,550 Yearly Maximum)

Dependent Care Flexible Spending Account

Monthly Cost

If participating, what is your monthly contribution?

($5,000 Yearly Maximum )