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

EPO 40/1000

EPO 30/1000A

EPO 30/1000

EPO 30/500

EPO 20A

EPO 20

PPO 25/1000

HMO 30/50/1000

HMO 30/50/500

HMO 25/40/500A

HMO 25/40/500

HMO 20/25/200

2 Tier 4 Tier

CS EPO 40/1000A (Renewals Only)

CS EPO 40/2000 (Renewals Only)

CS EPO 40/1000 (Renewals Only)

CS EPO 30/1000 (Renewals Only)

CS EPO 30/500 (Renewals Only)

CS PPO 30/2000 (Renewals Only)

CS PPO 30/2000A (Renewals Only)

EPO 40/1000 (Renewals Only)

EPO 30/1000A (Renewals Only)

EPO 30/1000 (Renewals Only)

EPO 30/500 (Renewals Only)

EPO 20A (Renewals Only)

EPO 20 (Renewals Only)

PPO 25/1000 (Renewals Only)

PPO 30/1000 (Renewals Only)

PPO 20/500 (Renewals Only)

2 Tier 4 Tier

3 Tier

EPO 30/50 1000A Select

EPO 30/50 1000 Select

EPO 25/1000 Select

EPO 15/1000 Select (Renewals Only)

PPO 15/1000 Select

PPO 30/50 1000 Select (Renewals Only)

PPO 25/1000 Select (Renewals Only)

HMO Super Value (Renewals Only)

HMO 25/40A (Renewals Only)

HMO Value (Renewals Only)

HMO 20 (Renewals Only)

HMO 5 (Renewals Only)

HMO 15 (Renewals Only)

HMO 10 (Renewals Only)

POS 20/1000

2 Tier 3 Tier 4 Tier

Direct Access HMO 20 (Renewals Only)

Direct Access HMO 15 (Renewals Only)

Direct Access HMO 10 (Renewals Only)

POS 20/1000 (Renewals Only)

POS 15/500 (Renewals Only)

POS 10/250 (Renewals 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 3000/100%

HSA High Deductible EPO 5800/100%

HSA High Deductible PPO 2500/100%

HSA High Deductible PPO 5000/100%

2 Tier 4 Tier

HSA High Deductible EPO Option #1        (Renewals Only)

HSA High Deductible EPO Option #2        (Renewals Only)

HSA High Deductible EPO Option #3        (Renewals Only)

HSA High Deductible EPO Option #4        (Renewals Only)

HSA High Deductible PPO Option #1        (Renewals Only)

HSA High Deductible PPO Option #2        (Renewals Only)

HSA High Deductible PPO Option #3        (Renewals Only)

HSA High Deductible PPO Option #4        (Renewals Only)

2 Tier 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