Plan Costs

Medical Plan 1

Employee Only: $XX

Employee and Spouse: $XX

Employee and Child(ren): $XX

Employee and Family: $XX

Medical Plan 2

Employee Only: $XX

Employee and Spouse: $XX

Employee and Child(ren): $XX

Employee and Family: $XX

Medical Plan 3

Employee Only: $XX

Employee and Spouse: $XX

Employee and Child(ren): $XX

Employee and Family: $XX

Dental Plan 1

Employee Only: $XX

Employee and Spouse: $XX

Employee and Child(ren): $XX

Employee and Family: $XX

Dental Plan 2

Employee Only: $XX

Employee and Spouse: $XX

Employee and Child(ren): $XX

Employee and Family: $XX

Vision Plan

Employee Only: $XX

Employee and Spouse: $XX

Employee and Child(ren): $XX

Employee and Family: $XX

Domestic Partner Coverage

Please note that unless your domestic partner is your tax dependent as defined by the IRS, contributions for domestic partner coverage must be made after-tax. Similarly, the company contribution toward coverage for your domestic partner and his/her dependents will be reported as taxable income on your W-2. Contact your tax advisor for more details on how this tax treatment applies to you. Notify [Company] if your domestic partner is your tax dependent.