Annual Salary
Coverage	Annual Cost
Medical Employee Only Employee + Spouse/DP Employee + Child(ren) Employee + Family
Dental Employee Only ($201.24) Employee + Spouse/DP ($390.72) Employee + Child(ren) ($461.52) Employee + Family ($650.88)
Vision Care Employee Only ($0.00) Employee + Spouse/DP ($22.08) Employee + Child(ren) ($23.40) Employee + Family ($60.12)
Additional Life             Multiplier                     Age            1x 2x 3x 4x 5x 6x 7x 8x Flat $50,000 Under age 30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+
Spouse/DP Life Insurance $10,000 ($31.20) $20,000 ($62.40) $30,000 ($93.60) $40,000 ($124.80) $50,000 ($156.00) $60,000 ($187.20) $70,000 ($218.40) $80,000 ($249.60) $90,000 ($280.80) $100,000 ($312.00) $110,000 ($343.20) $120,000 ($374.40) $130,000 ($405.60) $140,000 ($436.80) $150,000 ($468.00)
Child(ren) Life Insurance $5,000 ($12.00) $10,000 ($24.44) $15,000 ($36.40)
Legal Legal Opt In ($201.00)
Identity & Fraud Protection Employee Only ($96.60) Employee + Family ($159.00)
Group Accident Insurance Employee Only ($100.88) Employee + Spouse/DP ($152.62) Employee + Child(ren) ($199.94) Employee + Family ($255.84)
Group Hospital Indemnity Insurance Employee Only ($297.44) Employee + Spouse/DP ($458.64) Employee + Child(ren) ($601.12) Employee + Family ($761.28)
Critical Illness                                                 Age Employee Only Employee + Spouse/DP Employee + Child(ren) Employee + Family            Under age 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+
Health Savings Account (HSA) (Enter Annual Amount)
Dependent Care (Enter Annual Amount)
	Annual Cost
	$0.00
Cost Per Period Annual Cost 12 Pay Periods 26 Pay Periods