| Confirmation number | 14252120616 |
| Submitted | at 2:03pm ET |
| Per-Pay-Period Cost | $167.70 |
| Before-Tax | $146.42 |
| After-Tax | $21.28 |
You can make changes to this event until Nov 30, 2019 at 11:59pm ET.
| Per-Pay-Period Cost | You |
Pat |
Morgan |
Cameron |
|
|---|---|---|---|---|---|
|
Medical Consumer Choice HDHP (HSA Eligible) |
$271.84 01/01/ |
||||
|
Health Savings Account (HSA) No Coverage |
$0.00 01/01/ |
||||
|
Tobacco Surcharge I do not use tobacco products |
$0.00 01/01/ |
||||
|
Spouse Surcharge My working spouse is not eligible for other coverage |
$0.00 01/01/ |
||||
|
Critical Illness No coverage |
$0.00 01/01/ |
||||
|
Hospital Indemnity No coverage |
$0.00 01/01/ |
Dental DMO Plan |
$20.00 01/01/ |
||
|
Vision No Coverage |
$0.00 01/01/ |
||||
|
Health Care FSA No coverage |
$0.00 01/01/ |
||||
|
Dependent Care FSA No coverage |
$0.00 01/01/ |
||||
|
Basic Life 1 x Base Pay, $50,000 |
$0.00 01/01/ |
||||
|
Optional Life 5 x Base Pay, $250,000 |
$17.50 01/01/ |
||||
|
Spouse Life $20,000 |
$10.20 01/01/ |
||||
|
Long-Term Disability 40% of Base Pay, $20,000 |
$0.00 01/01/ |
||||
|
Legal Services No coverage |
$0.00 01/01/ |
||||
| Total | $319.54 | ||||
| Before-Tax | $291.84 | ||||
| After-Tax | $27.70 | ||||