Enrollment Completed! Action Required (see below)

Action Required (see below)

Confirmation number	14252120616
Submitted	Nov 18, at 2:03pm ET

You can make changes to this event until Nov 30, at 11:59pm ET.

A record of this transaction will be saved in transaction history.

Action Required

Complete your Evidence of Insurability (EOI) Online - you have 30 days to complete your EOI for Employee Supplemental Life Insurance. Until your provider approves your completed EOI, you will remain enrolled in 3x Pay coverage at a cost of $10.50 per pay period.
Verify your family members - because you have added a family member(s) to benefits coverage, you must provide proof of their eligibility for benefits. Failure to provide the requested materials by the deadline will result in their loss of coverage.
Make a COBRA payment - because you have enrolled in COBRA benefits coverage, you must provide payment. Failure to provide payment by the deadline will result in a loss of coverage.

Next Steps – now that you are done with your event, here are a few things to consider:

	Per-Pay-Period Cost	You	Pat	Morgan	Cameron
Medical Consumer Choice HDHP (HSA Eligible)	$120.00 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 Spending Account (HCSA) No coverage	$0.00 01/01/
Dependent Care Spending Account (DCSA) 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	$167.70
Before-Tax	$146.42
After-Tax	$21.28