Group Name:

HMO 25/40A

HMO 20A

HMO 25/40

HMO 20

HMO 25/40 Plus

HMO 20 Plus

POS 25/40 2000A

POS 20/2000

POS 25/40 2000

POS 20/1000

POS 25/40 1000 Plus

POS 20/500

2 Tier 4 Tier

CS EPO 40/1000A

CS EPO 40/2000

CS EPO 40/1000

CS EPO 30/1000

CS EPO 30/500

CS PPO 30/2000

CS PPO 30/2000A

EPO 40/1000

EPO 30/1000A

EPO 30/1000

EPO 30/500

EPO 20A

EPO 20

PPO 30/1000

PPO 25/1000

PPO 20/500

2 Tier 4 Tier

3 Tier

EPO 30/50 1000A Select

EPO 30/50 1000 Select

EPO 25/1000 Select

EPO 15/1000 Select

PPO 15/1000 Select

PPO 30/50 1000 Select

PPO 25/1000 Select

HMO Super Value

HMO 25/40A

HMO Value

HMO 20

HMO 5

HMO 15

HMO 10

POS 20/1000

2 Tier 3 Tier 4 Tier

Direct Access HMO 20

Direct Access HMO 15

Direct Access HMO 10

POS 20/1000

POS 15/500

POS 10/250

2 Tier 3 Tier 4 Tier

HMO 25A (Renewal Only)

HMO 20B (Renewal Only)

HMO 20A (Renewal Only)

HMO 25 (Renewal Only)

HMO 20 (Renewal Only)

HMO 15 (Renewal Only)

HMO 10 (Renewal Only)

POS 20/1000 (Renewal Only)

POS 10/500 (Renewal Only)

2 Tier 3 Tier 4 Tier

POS 20/2000 HRA Option #1

POS 20/2000 HRA Option #2

POS 20/2000 HRA Option #3

POS 20/2000 HRA Option #4

4 Tier

HSA High Deductible EPO Option #1

HSA High Deductible EPO Option #2

HSA High Deductible EPO Option #3

HSA High Deductible EPO Option #4

HSA High Deductible PPO Option #1

HSA High Deductible PPO Option #2

HSA High Deductible PPO Option #3

HSA High Deductible PPO Option #4

2 Tier 4 Tier

PPO HSA PLAN 22G

PPO HSA PLAN 22P

PPO HSA PLAN 29G

PPO HSA PLAN 30P

4 Tier

 

	# Employees	Monthly Employer Contribution
EE Only:
EE + Spouse /EE + One:
EE + Child(ren):
Family:

 
Select Pay Period: Monthly Bi-Monthly Every 2 weeks Weekly  Percentage Contributions: No Yes
 

Proposal	Rate Sheet	Proposal & Rate Sheet
Show Money Funded into HSA: yes    no