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2016 Benefits Guide
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ENROLLMENT WORKSHEET
Medical and Dental
Base
Base with
Spousal
Surcharge
Enhanced
My Per Pay
Cost
Enhanced
with Spousal
Surcharge
QHDHP
QHDHP with
Spousal
Surcharge
Employee
$27.00
$27.00
$54.00
$54.00
$22.00
$22.00
Employee & Spouse
$80.00
$105.00
$136.00
$161.00
$54.00
$79.00
Employee & Child(ren) $74.00
$74.00
$126.00
$126.00
$50.00
$50.00
Family
$132.00
$157.00
$207.00
$232.00
$96.00
$121.00
Vision
My Per Pay
Cost
Employee
$2.70
Employee & Spouse
$4.97
Employee & Child(ren)
$5.21
Family
$7.80
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
Flexible Spending Account/Health
Savings Account
My Monthly Cost
Medical Spending Account
Limited Medical Spending Account
Dependent Care Spending Account
Health Savings Account
Voluntary Life My Monthly Cost
Child(ren)
$__________
÷ 1,000 X $_________ = $_________
Amount of
Coverage
Unit Cost
from Rate
Table
Child(ren)
Monthly
Cost