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MISS MOLLY'S PASTRIES LLC | Miss Mollys Pastries 1JUL2020

Enrollment Dates: 6/29/2020 - 6/30/2020
Primary Phone: 708-497-5140
Work Phone:
Samantha Hanson Gender: Female
Employee ID:
2704 N Humboldt Blvd Birth Date: 4/25/1990
Milwaukee, WI 53212 Date of Hire: 6/30/2017
Classification:
Location: Milwaukee
Paychecks per Year: 26
Department: FO

Benefit Bank:
Allotted: $23.08
Used: $23.08
Remaining: $0.00
NEW ELECTION FORM Wednesday, July 8, 2020
Deduction Deduction
ID Election Description Action
Employee Employer
CLA-Post Short Term Disability *
Colonial (Samantha Hanson) New $9.85 $0.00
Off-Job Accident/Off-Job Sickness Disability. ($700.00 per Post-Tax
Month)
CLA-Post Term Life *
Colonial (Samantha Hanson) New $9.71 $0.00
30 Year Term Life. Non-tobacco rates. ($75,000.00) Post-Tax
Waiver of Premium Benefit
Critical Illness Accelerated Death Benefit
Chronic Care Accelerated Death Benefit ($75,000.00)
CLA-Pre Dental PPO *
Colonial (Samantha Hanson) New $18.40 $0.00
Individual Dental $2,000 Max with Rollover - 100/80/50 - MAC Pre-Tax
Vision Rider - Individual
(Colonial Pre-Tax $18.40) Pre-Tax Subtotal $18.40
(Colonial Post-Tax $19.56) Post-Tax Subtotal $19.56
Pre-Tax/Post-Tax Total $37.96
Benefit Bank ($23.08)
Grand Total $14.88 $0.00
(26 deductions per year)

This summary only includes benefits that are processed by this system.
* This application for coverage has been submitted to Colonial for review. If the application is approved you will receive a
policy. Coverage under the policy will not be effective until the policy/certificate is issued and the first premium is paid. If the
application is declined, you will be notified by Colonial.
I authorize my employer to reduce my salary or wages in the amount necessary to pay for the coverage selected. I understand
my payroll reductions will change if my coverage or costs change. I further direct any funds provided by my employer be
allocated as my coverage elections indicate.
If my employer is offering my coverage on a pre-tax basis through a Section 125 cafeteria plan or I have elected to pay for my
coverage on a pre-tax basis, I understand that any benefits I receive may be subject to federal and state income taxes. I also
understand that I will not be able to make changes in my elections during the plan year unless I have a “change in status” (such

https://harmonyenroll.coloniallife.com/V13/Core.Web/elections/BatchElectionForm.aspx?A... 7/8/2020