Pay Check Deductions:

                            

                                Group Medical Insurance                                  $_____________

                                Group Term Life Insurance                              $_____________

                                Group Dental Insurance                                    $_____________

                                Cancer, Intensive Care, Accident                    $_____________

                               

TOTAL COST:                                                    $_____________

 

Dependent Care Assistance:  $_________         x________ = _________

(How much do you pay for dependent care                   Weekly Expense                 # of Weeks            Total Yearly Cost

                       for children under 13 years.)  

 

Medical Expenses:                                     Projected Expenses

(Estimate your uninsured medical costs per year)

 

                                Insurance Deductibles                                       $_____________

                                Insurance Co-payments                                     $_____________

                                Dental Deductibles                                             $_____________

                                Dental Expenses                                                  $_____________

                                Vision Deductibles                                             $_____________

                                Vision Expenses                                                  $_____________

                                Hearing Expenses                                               $_____________

                                Prescriptions                                                       $_____________

                                Medically required equipment                          $_____________

                                Chiropractic                                                         $_____________

                                Other Medical Expenses                                    $_____________

 

TOTAL YEARLY COST:                                  $_____________

 

Individually Owned Health Insurance:

(Enter the annual premium amount of any of the following insurance plans that you or your dependents individually own)_­

                  

Dental Insurance                                                 $_____________

                                Vision Insurance                                                 $_____________

                                Cancer Insurance                                                $_____________

                                Intensive Care Insurance                                   $_____________

                                Accident Insurance                                             $_____________

 

                   TOTAL ANNUAL PREMIUM:                           $_____________

  

Total Deductions:                                      $_________

 

****You may meet with your benefits counselor to answer any questions and adjust your estimates according to your personal needs.****