| Confirmation number | 14252120616 |
| Submitted | Nov 18, 2017 at 2:03 PM ET |
| Per-Per-Pay-Period Cost | $327.15 |
| Before-Tax | $276.34 |
| After-Tax | $50.81 |
You can make changes to this event until Nov 30, 2017 at 11:59 pm ET.
A record of this transaction will be saved in transaction history.
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Medical
Basic Plan |
$120.00 01/01/ |
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Tobacco Surcharge
I do not use tobacco products |
$0.00 01/01/ |
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Working Spouse Surcharge
My working spouse is eligible for other coverage |
$0.00 01/01/ |
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Dental
DMO Plan |
$40.00 01/01/ |
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Vision
Standard Plan |
$21.50 01/01/ |
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Healthcare Flexible Spending Account
No coverage |
$0.00 01/01/ |
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Dependent Care Flexible Spending Account
No coverage |
$0.00 01/01/ |
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Basic Life
5 x Base Pay, $250,000 |
$17.50 01/01/ |
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Supplemental Life Insurance
3 x Base Pay, $150,000 |
$10.50 01/01/ |
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Spouse Life Insurance
$20,000 |
$10.20 01/01/ |
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Child Life Insurance
$5,000 |
$2.50 01/01/ |
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Short-Term Disability
No coverage |
$0.00 01/01/ |
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Long-Term Disability
40% of Base Pay, $20,000 |
$5.00 01/01/ |
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Critical Illness
No coverage |
$0.00 01/01/ |
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Accident Insurance
Coverage, You + Family |
$40.00 01/01/ |
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| Per-Pay-Period Cost | You |
Pat |
Morgan |
Cameron |
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|---|---|---|---|---|---|---|
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Medical High Deductible Health Plan |
$229.29 01/01/ |
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Health Savings Account (HSA) Enrolled |
$38.20 01/01/ |
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Biometric Surcharge Surcharge |
$0.00 01/01/ |
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Biometric Surcharge - Spouse Surcharge |
$0.00 01/01/ |
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Tobacco Surcharge Surcharge |
$0.00 01/01/ |
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Biometric Surcharge - Spouse Surcharge |
$0.00 01/01/ |
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Engagement Penalty Engagement Penalty |
$5.00 01/01/ |
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Dental DMO Plan |
$26.11 01/01/ |
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Vision Standard Plan |
$3.08 01/01/ |
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Limited Purpose Spending Account (LPSA) No coverage |
$0.00 01/01/ |
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Health Care Spending Account (HCSA) No coverage |
$0.00 01/01/ |
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Dependent Care Spending Account (DCSA) No coverage |
$0.00 01/01/ |
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Basic Life Insurance 1.5 x Annual Rate Coverage = $236,000 |
$17.50 01/01/ |
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Group Universal Life No coverage |
$0.00 01/01/ |
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Basic AD&D 1.5 x Annual Rate Coverage = $236,000 |
$0.00 01/01/ |
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Supplemental AD&D 3 x Annual Rate |
$0.00 01/01/ |
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Short-Term Disability 100% STD Plan |
$0.00 01/01/ |
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Long-Term Disability Base Monthly Pay |
$5.00 01/01/ |
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Hyatt Legal No coverage |
$0.00 01/01/ |
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| Total | $327.15 | |||||
| Before-Tax | $276.34 | |||||
| After-Tax | $50.81 | |||||