Annual Enrollment
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Personal Information

  • Name
  • First Name Terry
  • Middle Initial D
  • Last Name Smith
  • SSN 461-45-5627
  • Date
  • Date of Birth 9/3/1950
  • Status
  • Marital Status Married
  • Does your spouse work for the company? No

Contact Information

  • Home Address
  • Address 1234 Main St.
  • City Someplace
  • State TX
  • ZIP 12345
  • Telephone Number
  • Home Phone (312) 555-1212
  • First Name: Terry
    Last Name: Smith
    Relationship: Employee
    Age: 71
  • First Name: Pat
    Last Name: Smith
    Relationship: Spouse
    Age: 46
  • First Name: Morgan
    Last Name: Smith
    Relationship: Child
    Age: 11
  • First Name: Cameron
    Last Name: Smith
    Relationship: Child
    Age: 9
Medical
BCBS Standard Plan
Employee plus Chid(ren)
No Coverage
$195.75
Non Tobaco User Credit
Per paycheck credit: ($20)
($20.00)
Dental
Aetna Dental PPO
Employee plus Child(ren)
$28.99
Vision
Vision Plan
Employee plus Child(ren)
$7.34
Health Care Flexible Spending Account
N/A
$0.00
Dependent Care Spending Account
N/A
$0.00
Basic Employee Life Insurance
Basic Employee Life Insurance
$0.00
Optional Life Insurance
No Coverage
$0.00
Spouse Life Insurance
No Coverage
$0.00
Child Optional Life Insurance
No Coverage
$0.00
Optional Accidental Death and Dismemberment
No Coverage
$0.00
Occupational Accidental Death and Dismemberment
Occupational Accidental Death and Dismemberment
$0.00
Short Term Disability
No Coverage
$0.00
Long Term Disability
No Coverage
$0.00
Group Legal
No Coverage
$0.00
Critical Illness
No Coverage
$0.00
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