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CITY OF ORONO <br /> FLEX/BLE BENEFITS ENROLLMENT FORM <br /> Januarv 1 7n'I� — I7P�`AIYfI1AP �� 7l1�� <br /> �'��c.���A. t,J�i�\,. l`..t� � <br /> Pre-Tax Premiums <br /> REQU/RED "CORE"or EMPLOYER PA/D BENEFITS Per Month <br /> ■ Basic$10,000 Life and Accidental Death and Dismemberment Insurance �. $.95 <br /> MED/CAL COVERAGE OPTIONS: Enter the month/y cost of inedica/option in Box 2. Y6L�� vv <br /> 2. Xy <br /> Aware Network $2.500 Ded HRA $2,500 Ded HSA <br /> Single ❑$ 483.00 ❑$ 441.50 <br /> Employee+Spouse ❑$ 1013.50 ❑$ 927.00 <br /> Employee +Child(ren) ❑$ 965.00 ❑$ 883.00 <br /> Family �$1254.50 ❑$1148.00 <br /> Accord Network $2.500 Ded HRA $2,500 Ded HSA 3 �C-'�'�. �� <br /> Singie �i I$ 464.00 ❑$ 425.00 <br /> Employee+Spouse �$ 974.50 ❑$ 891.50 <br /> Employee +Child(ren) ❑$ 927.50 ❑$ 849.00 <br /> Famiiy ❑$1206.00 ❑$1104.50 <br /> If HRA option (select one) �Single(2500)HRA $104.17 ❑Family(5000)HRA $208.33 <br /> (Enter amount in Box 3.) <br /> ❑ I wish to waive medical coverage <br /> You must be covered by a group sponsored plan elsewhere and provide evidence of coverage in <br /> order to waive coverage. <br /> DELTA DENTAL COVERAGE OPTIONS: Check box in front of opfion you <br /> choose,enter the monthfy cosf in Box 4.Policy Number (OFFICE USE ONLY) 4 <br /> Select One: <br /> ❑ Single Dental Coverage for You $ 40.00 <br /> ❑ Single+One Dental Coverage for You $ 77.15 <br /> ❑ Family Dental Coverage for You and Your Dependents $ 106.35 <br /> HEALTH SAVINGS ACCOUNT CONTR/BUT10N (HSA ONL1� <br /> Annual Employee Contribution$ = 12 months = monthly contribution(Box 5) 5• <br /> FLEXIBLE SP,ENDING ACCOUNTS <br /> ��,. <br /> Health Care ReimbursementAccount � <br /> Annual Coverage$ (max.$1,800) = 12 months = monthly contribution g. <br /> Dependent Day Care Reimbursement Account <br /> Annual Coverage$ (max.$5,000) + 12 months = monthly contribution �. <br /> MONTHLY COST OF PRE-TAX BENEFITS <br /> Add Boxes 1 through 7 and enter total in Box 8. s. <br /> ,s6�_ �2, <br /> City of Orono <br />