Annual Enrollment
Deadline: Nov 30, 2017 at 11:59pm ET
Per-Pay-Period Cost
(effective date)

You

Pat

Morgan

Cameron
Medical
High Deductible Health Plan
$120.00
01/01/

Medical

1 Who do you want to cover?


You

Pat

Morgan

Cameron

3 Which Medical plan would you like?

Plan Options
View All Options
Waived
Compare Total Costs
$0.00
$48.50
$50.00
$52.50
$54.00
$57.50
$60.50
Health Savings Account
No coverage
$0.00
01/01/

Health Savings Account

1 Are you eligible to open a Health Savings Account?

Health Savings Account Eligibility

To be eligible to open a BenefitWallet HSA you must meeting all the criteria below Internal Revenue Service rules define "eligible individuals" as those who:

  • Are covered by a quiclified High Deductible Health Plan (HDHP).
  • Have no other coverage (such as coverage as a dependent under a spouse's employer's plan) that provides coverage with a deductible lower than the legally required minimum deductible for HDHPs.
  • Do not have a spouse enrolled in an employer's general purpose health care FSA plan or HRA.
  • Are not enrolled in Medicare, and
  • Cannot be claimed as a dependent or another individual's tax return.


2 How much do you want to contribute annually?

Annual Contribution Amount Per-Pay-Period Contribution
Employer money only $0.00 $0.00
Additional employee contributions
$
$0.00
By checking this box, I AGREE to open BenefitWallet Health Savings Account (HSA) electronically and receive electronic statements for my BenefitWallet HSA. I also acknowledge that I am eligible to participate in the program and I have read the terms and conditions and agree to be bound by the agreements and fee schedule."
Tobacco Surcharge
I do not use tobacco products
$0.00
01/01/

Tobacco Surcharge

1 Which option would you like?

Plan Options Per-Pay-Period Cost
I do not use tobacco products $0.00
I use tobacco products $15.00
Spouse Surcharge
My working spouse is not eligible for other coverage
$0.00
01/01/

Spouse Surcharge

1 Which option would you like?

Plan Options Per-Pay-Period Cost
I do not have a working spouse $0.00
My working spouse is not eligible for other coverage $0.00
My working spouse is eligible for other coverage $27.00
Critical Illness
No coverage
$0.00
01/01/

Critical Illness

1 Who do you want to cover?

You Only
You + Spouse
You + Child(ren)
You + Family

2 Which option would you like?

Plan Options Per-Pay-Period Cost
I do not have a working spouse $0.00
My working spouse is not eligible for other coverage $0.00
My working spouse is eligible for other coverage $27.00
Hospital Indemnity
No coverage
$0.00
01/01/

Hospital Indemnity

1 Which option would you like?

Plan Options Per-Pay-Period Cost
No coverage $0.00
Coverage $2.50
Dental
DMO Plan
$20.00
01/01/

Dental

1 Who do you want to cover?


You

Pat

Morgan

Cameron

2 What dental plan would you like?

Plan Options
View All Options
WaivedYou + Family
$0.00
$10.00$40.00
$12.50$39.00
Vision
No coverage
$0.00
01/01/

Vision

1 Who do you want to cover?


You

Pat

Morgan

Cameron

2 What vision plan would you like?

Plan Options
View All Options
WaivedYou + Family
$0.00
$10.00$5.00
$12.50$7.35
Healthcare Spending Account
No coverage
$0.00
01/01/

Healthcare Spending Account

1 How much do you want to contribute annually?

Annual Contribution Amount Per-Pay-Period Contribution
No coverage $0.00 $0.00
Coverage
$
Calculate $0.00
Dependent Care Spending Account
No coverage
$0.00
01/01/

Dependent Care Spending Account

1 How much do you want to contribute annually?

Annual Contribution Amount Per-Pay-Period Contribution
No coverage $0.00 $0.00
Coverage
$
Calculate $0.00
Basic Life
1 x Base Pay, $50,000
$0.00
01/01/

Basic Life Insurance

1 Which option would you like?

Plan Options Per-Pay-Period Cost
1 x Base Pay, $50,000 $0.00
2 x Base Pay, $100,000 $5.50
3 x Base Pay, $100,000 $10.20
Optional Life
5 x Base Pay, $250,000
Pending
$17.50
01/01/

Optional Life

1 Which option would you like?

Plan Options Coverage Amount Per-Pay-Period Cost
No coverage $0.00 $0.00
1 x Base Pay $50,000.00 $0.00
2 x Base Pay $100,000.00 $7.00
3 x Base Pay $150,000.00 $10.50
4 x Base Pay* $200,000.00 $14.00
5 x Base Pay* $250,000.00 $17.50

* Indicates you must complete Evidence of Insurability (EOI) for this level of coverage.

Spouse Life
$20,000
$10.20
01/01/

Spouse Life Insurance

1 Which option would you like?

Plan Options Per-Pay-Period Cost
No coverage $0.00
$10,000 $5.50
$20,000 $10.20
$30,000* $15.75
$40,000* $20.00

* Indicates you must complete Evidence of Insurability (EOI) for this level of coverage.

Long-Term Disability
40% of Base Pay, $20,000
$0.00
01/01/

Long-Term Disability

1 Which option would you like?

Plan Options Coverage Amount Per-Pay-Period Cost
No coverage $0.00 $0.00
40% of Base Pay $20,000.00 $5.00
60% of Base Pay $30,000.00 $7.50
Legal Services
No coverage
$0.00
01/01/

Legal Services

1 Which option would you like?

Plan Options Per-Pay-Period Cost
No coverage $0.00
Coverage $2.50
Total
$167.70
Before-Tax
$146.42
After-Tax
$21.28
 
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