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Employee Benefits document sample
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PINAL COUNTY EMPLOYEE BENEFITS 01/01/2009 24 Pays
Fill out and print when complete
Enter Employee Name:
The Pinal County Benefit Allowance and the Benefit Premiums are based on the Effective Date of Coverage and if necessary are pro-rated
accordingly.
BENEFIT OPTIONS ANNUAL PREMIUM
LIFE INSURANCE (Required) $10,000 Basic Life, AD&D and Basic Dependent Life
$ 41.00
MEDICAL PLANS ANNUAL COST
Employee Only $5,259
Employee & Spouse $7,159
Employee & Children $6,479
Employee & Family $8,229
$ 0.00
DENTAL PLANS ANNUAL COST
BASIC DENTAL
Employee Only $100
Employee & Family $215
EXTENDED DENTAL
Employee Only $290
Employee & Family $760
$ 0.00
VISION PLAN ANNUAL COST
Employee Only $65
Employee & Family $130
$ 0.00
EMPLOYEE ASSISTANCE PROGRAM
Employee & Family $0
$ NO CHARGE
EMPLOYEE SUPPLEMENTAL LIFE INSURANCE
Coverage in addition to the Basic Life Insurance – Maximum of 5 times current salary up to $350,000 – in $5,000 increments.
Complete the following steps to calculate the annual premium:
1. Select your age as of January 1, 2009
2. Enter your Alternative ID Number
3. Enter amount of Supplemental Life coverage
Annual Cost
1. Age Factor 2. Enter your Alternative ID Number here $
00-29 $0.48
30-39 0.72 Your salary is $
40-44 1.32
45-49 2.16 3. Enter Supplemental Life amount here $
50-54 4.08
55-59 6.36
60-64 7.20 Premium Calculation:
65-69 12.24 $ 0.00 x $ 0 = $ 0.00
70-74 21.48
Supplemental Life amout divided by 1,000
75+ 33.48
1 of 2
DEPENDENT SUPPLEMENTAL LIFE INSURANCE
Dependent Supplemental Life may not be elected unless Employee Supplemental Life has been elected.**
This benefit may not be purchased with the County Benefits Allowance.
I elect Dependent Supplemental Life. Check box if YES
Payroll after-tax Annual Cost: $23.52 $ 0.00
All Eligible Dependents – Spouse $5,000 & Children $1,000 each.
**You may only elect Dep Supp Life without EE Supp Life if you elected Dep Supp Life without EE Supp Life in the 2008 plan year
SHORT TERM DISABILITY
Complete the following steps to calculate the annual premium:
1. Select your age as of January 1, 2009
2. Enter your Alternative ID Number
Annual Cost
1. Age Factor 2. Enter your Alternative ID Number here
under 40 $0.0056
40-49 $0.0086
50 and over $0.0150
Your salary is:
Payroll after-tax premium calculation $ 0.0000 x $ = $ 0.00
FLEXIBLE SPENDING ACCOUNT
COMBINED MAXIMUM COUNTY BENEFIT CONTRIBUTION FOR FLEX IS $2,650
HEALTH CARE FLEXIBLE SPENDING ACCOUNT
Estimate the annual cost of health care expenses not covered by medical, dental & vision plans that
you expect to pay in the Plan Year.
Maximum Election is $2,650. Enter Election Amount here. $
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
Estimate the amount you will spend on dependent care (care for your dependents that enables you
and your spouse, if applicable, to work) in the Plan Year.
Maximum Election is $5,000 per family. Enter Election amount here. $
BENNY CARD
Benny Card may not be elected unless Health Care Flexible Spending has been elected.
I elect the Benny Card. Check box if YES
Payroll after-tax Annual Cost: $24.00 $ 0.00
1. TOTAL EMPLOYEE PREMIUMS (Total Cost of ALL Benefits Selected) $ 41.00
2. PINAL COUNTY EMPLOYEE BENEFIT ALLOWANCE USED (Max $5,300, but only a max of $2,650 can be $ -41.00
used towards Flexible Spending elections)
3. EMPLOYEE ANNUAL PREMIUM DEDUCTION & CONTRIBUTION $ 0.00
4. BI-WEEKLY APPROXIMATE PRE-TAX DEDUCTION (this is only an estimate) $ 0.00
BI-WEEKLY APPROXIMATE POST-TAX DEDUCTION (this is only an estimate) $ 0.00
NOTE: Completing this "Pinal County Benefits" worsheet online does not mean that you have enrolled.
Should you have any questions or need additional information regarding your benefits, please refer to the Pinal County Benefit “Highlight”
Booklet or “Benefit Plan Document” or call Mountain States Administrative Services at (800) 866-4731. 2 of 2
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