Employee Health Insurance Renewal Employee Name Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Email Phone Covered Dependents Dependent Name Relationship Operations Dependent Name Relationship Dependent Name Relationship Dependent Name Relationship Health Plan I am waiving health coverage for this plan year Weekly pretax deduction Gold EE Only108.42 ES244.39 Family357.89 ECH221.65 Silver EE Only65.36 ES169.59 Family261.43 ECH137.33 HSA-3500/7000 EE Only24.95 ES93.34 Family101.02 ECH62.69 HSA-6500/13000 EE Only- ES67.99 Family86.61 ECH61.66 Add weekly pre-tax deduct for Health Savings Plan Dental EE Only5.78 EE+111.64 Family19.29 ECH11.64 Waive Dental Vision EE Only0.83 ES1.66 Family2.53 ECH1.7 Waive Vision Employee Signature Sign above
