Employee Health Insurance Renewal Employee Name Address Address Address 2 City/Town State/Province - Select - Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon 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
