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2015 Benefits Guide
12
ENROLLMENT WORKSHEET
Medical / Dental / Vision
Plan 1
Per Paycheck
Employee
$48.00
Employee & Spouse
$194.00
Employee & Child(ren)
$209.00
Family
$252.00
TOTAL 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