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 Only86.86 ES212.77 Family311.50 ECH199.08 Silver EE Only52.26 ES157.55 Family211.16 ECH112.48 HSA-3500/7000 EE Only19.78 ES51.70 Family80.43 ECH50.08 HSA-6500/13000 EE Only- ES52.08 Family61.15 ECH33.54 Add weekly pre-tax deduct for Health Savings Plan Dental EE Only4.74 EE+18.53 Family14.16 Waive Dental Vision EE Only0.82 ES1.66 Family2.53 ECH1.7 Waive Vision Employee Signature Sign above
