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Home Delivery Incontinent Supply Co.
17
ENROLLMENT WORKSHEET
Medical
Base
Buy Up
QHDHP
My Per Pay Cost
Employee
$95.84
$39.91
$31.43
Employee & Spouse
$432.78
$320.92
$303.96
Employee & Child(ren)
$345.64
$247.76
$232.92
Family
$694.20
$540.39
$517.01
Dental
Base
Buy Up
My Per Pay Cost
Employee
$8.44
$10.32
Employee & Spouse
$28.59
$36.56
Employee & Child(ren)
$28.59
$36.56
Family
$28.59
$36.56
Vision
My Per Pay Cost
Employee
$1.74
Employee & Spouse
$3.81
Employee & Child(ren)
$3.92
Family
$6.14
VOLUNTARY LIFE/AD&D—PLEASE CONTACT
KAREN CZACHOWSKI x5386
FOR PLAN AND RATE SPEFIFICS
Spouse rates are based on the employee’s age
Health Savings Account
My Per Pay Cost
Voluntary Life My Monthly Cost
Employee
$________ ÷ 1,000 X $_______ = $_______
Amount of
Coverage
Unit Cost
from Rate
Table
Employee
Monthly Cost
Spouse
$________ ÷ 1,000 X
$_______
___
= $___________
Amount of
Coverage
Unit Cost
from Rate
Table
Spouse Monthly
Cost
Voluntary Life My Monthly Cost
Child(ren)
$__________
÷ 1,000 X $_________ = $_________
Amount of
Coverage
Unit Cost
from Rate
Table
Child(ren)
Monthly
Cost