Page 22 - Benefit Guide

Benefit costs

Your [monthly] payroll contributions for medical, dental and vision benefits are shown here:

Medical [Plan Name] [Plan Name] [Plan Name] [Plan Name]
Individual $XX $XX $XX $XX
Employee/Spouse $XX $XX $XX $XX
Employee/Children $XX $XX $XX $XX
Family $XX $XX $XX $XX

Dental [Plan Name] [Plan Name] [Plan Name] [Plan Name]
Individual $XX $XX $XX $XX
Employee/Spouse $XX $XX $XX $XX
Employee/Children $XX $XX $XX $XX
Family $XX $XX $XX $XX

Vision [Plan Name] [Plan Name] [Plan Name] [Plan Name]
Individual $XX $XX $XX $XX
Employee/Spouse $XX $XX $XX $XX
Employee/Children $XX $XX $XX $XX
Family $XX $XX $XX $XX

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