Page 19 - FSSI EE Guide 07-20 - OOS

MEDICAL PLANS : Please check one of the medical plan options listed below
Employee Only Employee + 1 Employee + Family DECLINE
PPO Savings Plan $601.75 $725.94  $1,119.19 

PPO Traditional Plan $848.51 $1,018.20  $1,569.73 
DENTAL PLANS : Please check one of the medical plan options listed below
Employee Only Employee + 1 Employee + Family DECLINE

Dental PPO $59.36 $57.33  $110.20 
VISION PLAN : Please check one of the medical plan options listed below

Employee Only Employee + 1 Employee + Family DECLINE
VSP $7.89 $4.36 $11.55 

Total Elected Coverage:
FSSI Allotment: ( ) ( ) ( )
Monthly Healthcare Costs: + + =

MONTHLY TOTAL HEALTHCARE COST: $

Monthly Total $ X 12/26=
Healthcare Costs: $
TOTAL DEDUCTION PER PAY PERIOD

LIFE/AD&D

$50,000 Life/AD&D Insurance
Coverage VOYA FSSI Sponsored Benefit

Voluntary Life/AD&D Insurance VOYA
Coverage Amount Cost
Employee $

Spouse $ TOTAL DEDUCTION PER PAY PERIOD:
$
Child $ (Monthly contributions $ ____ X 12/26)

TOTAL:
Voluntary Long-Term Disability VOYA
Employee $ TOTAL DEDUCTION PER PAY PERIOD
LTD $
(Monthly contributions $_____ X 12/26)