Page 26 - QSC Benefits Guide 7-17 COLORADO

YOUR COST FOR COVERAGE - PER PAYCHECK

This chart compares the per paycheck contributions for our Employee Benefit plans. Your cost for coverage will vary depending
on the options and level of coverage you choose.

Vision - EyeMed Voluntary Pet Health Care Program - United
Pet Care (Partner Program)
Employee Only $2.00
Employee + Spouse $3.00 One Pet $4.89
Employee + Child(ren) $4.00 Two Pets $9.32
Employee + Family $5.00 Three Pets $13.66
Each Additional Pet $4.29
Dental Option 1 - DMO - Cigna
Voluntary Pet Health Care Program - United
Employee Only $3.00
Pet Care (Select Program)
Employee + Spouse $6.00
One Pet $4.04
Employee + Child(ren) $4.00
Two Pets $7.66
Employee + Family $9.00
Three Pets $11.22
Each Additional Pet $3.55
Dental Option 2 - PPO - Cigna
Employee Only $10.00 Voluntary Pet Health Care Program -
Employee + Spouse $15.00
Nationwide
Employee + Child(ren) $14.00
Provided by Nationwide
Employee + Family $25.00

Critical Illness
Dental Option 3 - Premier PPO - Cigna Accident Insurance
Employee Only $20.00 Hospital Care
Employee + Spouse $30.00 Provided by Cigna
Employee + Child(ren) $25.00
Employee + Family $40.00 LifeLock Benefit Elite
Employee Only $3.92
Basic Life and AD&D Employee + Spouse $7.84
Long Term Disability Employee + Child(ren) $6.86
Employee Assistance Program Employee + Family $10.78
Travel Assistance
Employee Only No Charge LifeLock Ultimate Plus

Employee $11.76
Voluntary Legal Plan - Legal Shield Employee + Spouse $23.53
Tier 1 (Basic benefit plus $7.36 Employee + Child(ren) $16.67
Legal Shield)
Employee + Family $28.44
Tier 2 (Tier 1 plus Identity $11.95
Theft)
Note

You have the option for your Medical, HSA, Vision, Dental and Flexible Spending Account premiums to be deducted from
your paycheck on a pre-tax or post-tax basis. If you elect pre-tax, your premiums will be deducted from your paycheck
before federal (and in some cases, state) income and Social Security taxes are deducted, thereby lowering your taxes and
increasing the amount of your take-home pay.
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