Page 27 - QSC Benefit Summary 7-18 COLORADO

YOUR COST FOR COVERAGE

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

BIWEEKLY RATES BIWEEKLY RATES

Accident Insurance Basic Life and AD&D
Critical Illness Long Term Disability
Employee Assistance Program
Available on UltiPro
Travel Assistance
Dental Employee Only No Charge
Dental Option 1 Voluntary Life
DMO Voluntary AD&D
Employee Only $3.00 Voluntary Short Term Disability
Employee + Spouse $6.00
Available on Ultipro
Employee + Child(ren) $4.00
Employee + Family $9.00 LifeLock Benefit Elite
Dental Option 2 Employee Only $3.92
PPO
Employee Only $10.00 Employee + Dependents $7.84
Employee + Spouse $15.00
Employee + Child(ren) $14.00 LifeLock Ultimate Plus
Employee + Family $25.00 Employee $11.76
Dental Option 3 Employee + Dependents $23.53
Premier PPO
Employee Only $20.00
Employee + Spouse $30.00
Employee + Child(ren) $25.00
Employee + Family $40.00
Vision
Employee Only $2.00
Employee + Spouse $3.00
Employee + Child(ren) $4.00
Employee + Family $5.00

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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