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2015 Benefits Guide
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ENROLLMENT WORKSHEET
Package 1
Package 2
Per Paycheck
Employee
$80.29
$58.65
Employee & Spouse
$330.38
$286.63
Employee & Child(ren)
$305.16
$255.36
Family
$555.38
$483.31
Long Term Disability
TOTAL DEDUCTIONS PER PAYCHECK
DEPENDENT PARTICIPATION DETAIL
Legal Name
SS#
Relationship Gender
DOB
Medical
Yes or
No
Dental
Yes or
No
Vision
Yes or
No
Basic Life Primary Beneficiary - Total Must Equal 100%
Name
SS#
Relationship
%
Name
SS#
Relationship
%
Basic Life Contingent Beneficiary(s) - Total Must Equal 100%
Name
SS#
Relationship
%
Name
SS#
Relationship
%
BENEFICIARY INFORMATION