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CITY OF ORONO <br /> FLEXIBLE BENEF/TS ENROLLMENT FORM <br /> � ;��j��. U 5 t C.c��+,��c�► Dv'4��p ti1 � s.� o��c- �r.s; <br /> Pre-Tax Premiums <br /> REQUIRED "CORE"or EMPLOYER PAID BENEFITS Per Month <br /> ■ Basic$10,000 Life and Accidental Death and Dismemberment Insurance �. $,95 <br /> MEDICAL COVERAGE OPTIONS: Enter the monthly cost of inedicai option in Box 2. 2 l�/<jI`� �j'Q <br /> Aware Network $2,500 Ded HRA $2,500 Ded HSA <br /> Single ❑$ 483.00 � 441.50 <br /> Employee+Spouse ❑$1013.50 0$ 927.00 <br /> Employee +Child(ren) ❑$ 965.00 ❑$ 883.00 <br /> Family ❑$1254.50 ❑$1148.00 <br /> Accord Network $2.500 Ded HRA $2,500 Ded HSA 3 <br /> Single ❑$ 464.00 ❑$ 425.00 <br /> Employee+Spouse ❑$ 974.50 ❑$ 891.50 <br /> Employee +Child(ren) ❑$ 927.50 ❑$ 849.00 <br /> Family ❑$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 /> �,�__. : ,�u:., ,..,.,..�.� .,a.,.,.:.,._, <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 option you <br /> choose,enter the monthly cost in Box 4.Policy Number (OFFICE USE ONLY) 4• ��•�� <br /> Select One: <br /> �ingle 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 SAV/NGS ACCOUNT CONTR/BUTION (HSA ONL� <br /> Annual Employee Contribution$�.��� = 12 months = monthly contribution(Box 5) 5' Z,�Q.�D <br /> FLEXIBLE SPEND/NG ACCOUNTS <br /> Hea/th Care Reimbursement Account A <br /> Annual Coverage$ (max.$1,800) = 12 months = monthly contribution g. <br /> Dependent Day Care Reimbursement Account <br /> Annual Coverage$ (max. $5,000) = 12 months = monthly contribution 7_ <br /> MONTHLY COST OF PRE-TAX BENEFITS <br /> Add Boxes 1 through 7 and enter total in Box 8. 8 �82 . t�� <br /> City of Orono <br />