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C1TY OF ORONO <br /> ;, „ FLEX/BLE BENEFITS ENROLLMENT FnQ�v► <br /> ��.�;�� �a�e��.� <br /> Pre-Tax Premiums <br /> REQUIRED "CORE"o�EMPLOYER PAID BENEFITS Per Month <br /> ■ Basic$10,000 Life and Accidental Death and Dismemberment Insurance �• $.95 <br /> MEDICAL COVERAGE OPTIONS: Enter the monthly cost of inedical option in 8ox 2. � <br /> 2. <br /> Aware Network 52.500 Ded HRA 52.500 Ded HSA <br /> Single ❑$ 483.00 ❑$ 441.50 <br /> Employee+Spouse ❑$1013.50 ❑$ 927.00 <br /> Employee +Child(ren) ❑$ 9fi5.00 ❑$ 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 /> 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�PTIONS: Check box in front of opfion you <br /> choose, enfer the month/y cost in Box 4.Policy Number (OFFICE USE O v� 4� <br /> Seiect One: `/ <br /> rJ Single Dental Coverage for You $ 40.00 ` ���"� <br /> � Single+One Dental Coverage for You $ 77.Y5 V <br /> �7 Family Dental Coverage for You and Your Dependents $ 1U6.35 <br /> „� HEALTH SAVINGS ACCOUNT CONTR/BUTION (HSA ONLI� <br /> ��� _ Annual Employee Contributio; ��SrJ•� = 12 months = monthly contnbution(Box 5) <br /> 5� � 53� Sa <br /> FLEX/BLE SPENDING ACCOUNTS <br /> liealth Care Reimbursement Account <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� 3 �� .L�� <br /> �k <br /> � City of Orono <br /> V �� <br />