Enrollment Wizard

Welcome, Tom A. Adams

Enrollment Summary

Steps
	1.	Instructions
	2.	Personal Information
	3.	Dependents
	4.	Confirm Information
	5.	Medical Benefits
	6.	Dental Benefits
	7.	Vision Benefits
	8.	Disability Benefits
	9.	Life & Accident Benefits
	10.	FSA Benefits
	11.	Other Benefits
	12.	Beneficiary Information
	13.	Confirm and Submit

VIEW CURRENT BENEFITS SUMMARY

Confirm and Submit	Step 13 of 13
Please review your elections to ensure that they are correct prior to submitting them. Once submitted, your elections will remain in effect until the end of the plan year unless you experience a family status change.

Benefits Summary with effective date of 01/01/2005

Plan

Date
Eligible

Employee
Cost

Company
Cost

Basic AD&D

Type:	Basic AD&D
Coverage:	5 x Salary + $1,000 (Base) + $1,000
Total Amount:	$10,000
Dependents:	N/A

1/1/2000

$2.00

Basic Life

Type:	Basic Life
Coverage:	1 x Salary (Base)
Total Amount:	$47,424.00
Dependents:	N/A

1/1/2000

$0.00

$4.00

Blue Care Network HMO

Type:

Medical

Coverage:

Family

Dependents:

Name	Relationship
Jane A. Adams	(Spouse)
Jill A. Adams	(Child)
Ralph A. Adams	(Child)
Penelope Adams	(Child)

1/1/2000

$162.63

$91.23

Delta DMO

Type:

Dental

Coverage:

Family

Employee PCP ID: OKS2141

Dependents:

Name	Relationship	PCP ID
Jane C. Adams	(Spouse)	OKS2141
Jill A. Adams	(Child)	OKS2141
Ralph A. Adams	(Child)	OKS2141
Penelope Adams	(Child)	OKS2141

1/1/2000

$21.74

$24.15

Long Term Disability

Type:	LTD
Coverage:	1 x Salary (Base)
Total Amount:	$10,000
Dependents:	N/A

1/1/2000

$2.00

Short Term Disability

Type:	STD
Coverage:	$10,000 (Base)
Total Amount:	$10,000
Dependents:	N/A

1/1/2000

$2.00

Vision Service

Type:

Vision

Coverage:

Family

Dependents:

Name	Relationship
Jane C. Adams	(Spouse)
Jill A. Adams	(Child)
Ralph A. Adams	(Child)
Penelope Adams	(Child)

1/1/2000

$11.45

$12.65

Total

$219.82

$138.03

TBD - Cost will be calculated by the HR administrator during validation.

Beneficiary Information

Beneficiary Name	Relation	Distribution
Beneficiary Name	Relation	Primary	Contingent
Basic Life
Jane C. Adams	Spouse	20%	20%
Jill A. Adams	Child	20%	20%
Jean L. Picard	Stepson	20%	20%
Ralph A. Adams	Child	20%	20%
Penelope Adams	Child	20%	20%
Total		100%	100%
Voluntary Life
Jane C. Adams	Spouse	20%	20%
Jill A. Adams	Child	20%	20%
Jean L. Picard	Stepson	20%	20%
Ralph A. Adams	Child	20%	20%
Penelope Adams	Child	20%	20%
Total		100%	100%

Another Version