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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 )