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2016-2017 Benefits Guide
16
ENROLLMENT WORKSHEET
For Employee Use only-do not turn in to HR
Medical
Monthly Cost
Employee
Employee & Spouse
Employee & Child(ren)
Family
Dental
Monthly Cost
Employee
Employee & Spouse
Employee & Child(ren)
Family
Vision
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 $3,400; 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?
($2,500 Yearly Maximum)
Limited Flexible Spending Account
(with an HSA)
Monthly Cost
If participating, what is your monthly contribution?
($2,500 Yearly Maximum)
Dependent Care Flexible Spending Account
Monthly Cost
If participating, what is your monthly contribution?
($5,000 Yearly Maximum )