ABOUT YOU
Employer: Interim HealthCare Benefit Classification ER ID#:
Last Name First MI SSN
Gender DOB Projected Annual Compensation: $
Home Address: City State Zip
Home Phone Cell Work (434) 295-5501 Date of Eligibility
DO YOU WISH TO PARTICIPATE?
YES, I wish to participate in my employer’s benefit program and agree to the payroll deductions indicated below.
NO, I do not wish to participate. I waive my right to participate in the benefit plans and understand
I cannot enroll until the next open enrollment.
Signature Date
IF YES, PLEASE USE THE WORKSHEETS TO COMPLETE THE INFORMATION BELOW
CALCULATE TOTAL MONTHLY COST. Use the provided worksheets to determine amounts.
YOUR DENTAL INSURANCE
YOUR VISION INSURANCE
YOUR SHORT-TERM DISABILITY INSURANCE
MINIMAL ESSENTIAL COVERAGE INSURANCE
TOTAL THE MONTHLY COSTS FROM THE ABOVE BOXES
12
TOTAL ANNUAL COST
LESS EMPLOYER SUBSIDY
52
EMPLOYEE’S WEEKLY PAYCHECK COST
INDEMNITY MEDICAL HEALTH INSURANCE
Supplemental Plans Enrollment Sum ary
Net Employee Annual Cost
