All changes to the medical plans are subject to review before the selections below will take effect. Please submit you request for a change in benefits below.

Annual Company Contribution	$2000
My Base Salary	$41314.01
Total Benefits & Compensation	$43314.01

Medical Plan

You currently have elected Aetna POS plan. You have Family coverage, and your premium is $64.14 per pay period or $128.27 per month

Provider

Coverage

My Pay Period Contribution	$64.14
Annual Contribution	$1,667.64
Reset	Submit Changes

Life Insurance

You currently have elected $200,000 of term coverage, and your premium is $3.20 per pay period or $6.40 per month.

Provider

Coverage

Beneficiary Information

PRIMARY

Jane Doe
32 Blake Street
Newburgh, NY 12550

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SECONDARY

Jane Doe
32 Blake Street
Newburgh, NY 12550

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My Pay Period Contribution	$600
Annual Contribution	$43,314.01
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Dental Plan

You currently have elected the Delta Dental Plan with Family coverage, and your premium is $32.00 per pay period or $64.00 per month

Provider

Coverage

My Pay Period Contribution	$32
Annual Contribution	$832.00
Reset	Submit Changes