Benefit Pre-Enrollment

Monthly Rates Only

The following are benefits available to our valued employees, item 1, 2 and 3 are company sponsored benefits which we co-op the cost with you. Your selection will determine the contribution and authorize us to deduct the premium/contribution amounts under company Section 125 cafeteria compensation, pre-tax from your paycheck 30 days prior to the actual coverage's begin. Please review THE SPD for more details. 
A. Employer Sponsored Benefits  
MEDICAL EE EE+CH EE+SP Family
Aetna Open Access elect choice $0.00 $54.92 $108.00 $145.85
Easy PPO $36.46 $117.69 $203.54 $270.00
1. Medical Premium            Enter Your Premium from above

$

DENTAL EE EE+CH EE+SP Family
Managed - Basic $3.17 $6.32 $5.81 $7.69
Indemnity $8.08 $17.54 $13.85 $23.54
2. Dental Premium             Enter Your Premium from above

$

VISION   EE Family  
Great Eye   $0.00 $4.81  
3. Vision Premium             Enter Your Premium from above

$

Voluntary  Insurance
1. Accident/Cancer/Hospital

$

2. Group Term (up to $50,000 deductible)

$

Flexible Spending Account
1. Physical Exams/Co-Payments/Drugs etc.

$

2. Glasses/Contacts/Supplies

$

Other Expense
1. Health Care Related Travel [$.10 a mile + parking]

$

2. Lodging [to $50 per night]

$

3. Other - refer to health care list

$

B. DEPENDENT CARE EXPENSES
[Up to $5,000 per household, per calendar year, for dependent adults of any age and children up to age 13.]

$
C. ANNUAL INCOME
Include Spouse if Joint Filer
D. TAX FILING STATUS
If your family income level is $32,121 or below and you have 1 or more dependent(s), you may qualify for Earned Income Credit & Your children may qualify for Special Low Cost Health Insurance. (please click on the link to get more information)

Click here for Glossary of Cafeteria Plan

Optional 401k enrollment center
TAX SAVINGS WITH SECTION 125 PLAN
Total Actual Monthly Benefit Deduction(s)
Semi-monthly Estimated Tax Savings
Monthly Estimated Tax Savings

(Click here for enrollment applications)

Sample Application