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Infinity Resources, Inc.

Confirmation Statement

Name: Adams, Tom A. SSN: XXX-XX-2324
Address: 118 Apple Lane
Detroit, MI 80138
 Division:
Location:
Class:
 East
Montreal
Full-time

This statement confirms your recent enrollment elections. Please keep a copy of this statement for your records and use it to verify your paycheck stub. These benefits elections will remain in effect until 04/04/2003. If an error has been made in recording your dependent information, please make the appropriate corrections on this confirmation statement and return to your company representative.


Benefit Plan Name Coverage Effective Date Cost per
Pay Period
Medical Blue Care Network HMO Family 04/04/2002 44.03
Dental Dental DMO Plan Family 04/04/2002 12.98
Vision Vision Service Plan Employee + Spouse 04/04/2002 11.45
Disability Short Term Disability $10,000 (Base)
$10,000 		04/04/2002 2.00
Disability Long Term Disability 1 x Salary (Base)
$10.000 		04/04/2002 2.00
Life Basic Life Plan 2 x Salary + $2,000
$10,000.00 		04/04/2002 2.00
AD&D Basic AD&D Plan 5 x Salary + $1,000 (Base) + $1,000
$5,000.00 		04/04/2002 2.00
FSA Dependent Care Reimbursement FSA $2,500.00 04/04/2002 2.00
FSA Health Care Reimbursement FSA $5,000.00 04/04/2002 2.00
Dollar Amount Spent Per Pay Period $120.14

Dependent Information:
Below is a summary of information for your dependents which you have elected to cover under your benefits. If any information is incorrect or missing, please make changes below.

Name SSN Relationship Sex DOB Medical Dental Vision
Jane C. Adams
 255-44-4111
 Spouse F 11/05/1954
 Yes Yes Yes
Jill A. Adams
 323-33-3333 Child F 01/21/1971
 Yes Yes No
Ralph A. Adams
 333-33-3333 Child M 02/24/1978
 Yes Yes No
Penelope Adams
 776-66-7676 Child F 10/19/1975
 Yes Yes No

Beneficiary Information:
Below is a summary of information for your beneficiary information currently on record. If any information is incorrect or missing, please make changes below.

Basic Life Plan
Name Relationship Primary Contingent
Jane C. Adams Spouse 20% 20%
Jill A. Adams Child 20% 20%
Jean L. Picard Other 20% 20%
Ralph A. Adams Child 20% 20%
Penelope Adams Child 20% 20%

Voluntary Life Plan
Name Relationship Primary Contingent
Jane C. Adams Spouse 20% 20%
Jill A. Adams Child 20% 20%
Jean L. Picard Other 20% 20%
Ralph A. Adams Child 20% 20%
Penelope Adams Child 20% 20%


I understand that I may not make changes to these elections during the plan year unless I experience a qualified life event as set forth by the plan. I also authorize my employer to take any required premiums or contributions from my pay on a pre-tax or post-tax basis as stipulated by the plans included in my elections.


Signature:________________________________________________ Date: ______________________