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MEDICAL & VISION PLANS $250 ind/$750 fam ded, $2000 ind/$4000 fam out of pocket max, 15% office visit co‐pay, 15%/40% hospital co‐insurance 5%/10%/$100 ded/30%/50%, $2000 OOP, Prescription Vision: No co‐pay on annual exam, $150 hardware every 24 months EMPLOYEE 818.37 818.37 300‐1 EMPLOYEE & SPOUSE 1,491.21 1,289.36 300‐2 EMPLOYEE & CHILDREN 1,323.00 1,171.61 300‐3 EMPLOYEE & FAMILY 1,995.84 1,642.60 300‐4 HEALTH SAVINGS ACCOUNT (HSA) & VISION PLANS Must Pay ALL of Ded 1st, then pays 15%/40% of medical, hospital, emergency room, prescriptions until total out of pocket is met. $1400 ind/$2800 fam ded, plus $4200/$8400 out of pocket max, 306‐1 5%/10%/$100 ded/30%/50%, $2000 OOP, Prescription Vision: No co‐pay on annual exam, $150 hardware every 24 months Contribution Limits: Under 55‐$3450 ind/$6900 fam. Over 55: $4450 ind/$7,900 fam EMPLOYEE 749.42 818.37 68.95 0.00 301‐1 EMPLOYEE & SPOUSE 1,347.34 1,289.36 0.00 57.98 301‐2 EMPLOYEE & CHILDREN 1,212.44 1,171.61 0.00 40.83 301‐3 EMPLOYEE & FAMILY 1,752.03 1,642.60 0.00 109.43 301‐4 145.53 302‐1 25.00 302‐90 50.00 302‐91 1) Uniform Dental Plan (Group 3000) or $50 deductible in‐network,100% Preventive, $1750 annual max, 80% basic, 50% major, adult & child orthodontia EMPLOYEE 0.00 0.00 EMPLOYEE & SPOUSE 0.00 0.00 EMPLOYEE & CHILDREN 0.00 0.00 EMPLOYEE & FAMILY 0.00 0.00 2) WILLAMETTE or IN NETWORK ONLY ‐ Managed Care Plans, Set Rates & No Max Benefit PREMIUM County Pays EMPLOYEE 0.00 0.00 EMPLOYEE & SPOUSE 0.00 0.00 EMPLOYEE & CHILDREN 0.00 0.00 EMPLOYEE & FAMILY 0.00 0.00 LIFE INSURANCE & AD & D Life & LTD Only Applicable only IF enrolled in Medical PREMIUM County Pays Employee $35,000 & Additional $5000 for accidental death 0.00 0.00 X LONG TERM DISABILITY (LTD) ‐ Standard Insurance Co. 0.00 0.00 X Mark DC Flexible Spending Account (FSA), Max $2,600 ‐ Plus Point FSA/DCR Fee $5.00 92‐95 $ 92‐5 Dependent Care Reimbursement (DCR) Max $2,500/$5,000 ‐ Plus Point 92‐15 Voluntary Long Term Disability Plan (Income protection if disable) 316‐1 MARK ONE EMPLOYEE PAYS EMPLOYEE PAYS MARK ONE EMPLOYEE PAYS 0.00 or, MARK ONE Administered by Delta Dental Selection Sheet for PEBB Insurance Deductions - Klickitat County Full Time - Effective January 1, 2018, premiums reflected on your Dec. 25th payroll check Go to the Web - Health Care Authority, Public Employees Benefits Board, for Benefit Descriptions at: Print Last Name: Signature: Emp No: www.hca.wa.gov/pebb Date: Ded Code Uniform Medical Plan (UMP) ‐ Classic Premium Includes: Dental, Vision, Life Insurance & EE LTD Coverage ‐ Administered by Regence Emp HSA Contribution: County contributes 100% for Employee Medical, Dental, Vision, Life Insurance & LTD & COUNTY PAYS 0.00 I hereby authorize the deductions below and acknowledge that I have been informed of my COBRA rights. C h o o s e O n e P l a n 0.00 EMPLOYEE PAYS 201.85 151.39 353.24 0.00 C h o o s e O n e P l a n 70% of the Additional Cost for Dependent Medical, Dental, Vision, Life Ins & LTD Coverage (County Pays an Avg of 86% for Dep) Tobacco Surcharge: If you, or a dependent covered by the plan, use tobacco products PREMIUM MARK IF CONTRIB. TO HSA PREMIUM $ MARK ONE Ded Code MARK ONE COUNTY PAYS COUNTY PAYS 3) DELTA CARE (Group 3100) UMP Consumer‐Directed Health Plan (CDHP) (HSA) ‐ Premium Includes: Dental, Vision, Basic Life Insurance & EE LTD Coverage ‐ Regence EMPLOYEE PAYS Spouse or Dom. Partner Coverage Surcharge (go to Spousal Plan Calculator on the web) Waiver Fee: If you waive medical, you must be on dental, life & LTD COUNTY PAYS TO HSA 305‐1 Dental Plans You May Select One of the Following (place in small box) Employees can place dep on dental plans, without placing on medical. PREMIUM $ After 90 days being disabled, 60% of 1st $400 of current earnings. Min $50 & Max $240 per month 0.00 0.00 VOLUNTARY TAX SAVING PLANS OR ADDITIONAL INSURANCE SELECTION 0.00 MetLife ‐ Life Ins & Standard ‐ LTD Amount 0.00 0.00 0.00 0.00 All Self‐ Paid All Self‐ Paid ---PAGE BREAK--- MEDICAL & VISION PLANS $250 ind/$750 fam ded, plus $2000 ind/$4000 fam out of pocket max, 15% office visit co‐pay, 15%/40% hospital co‐insurance 5%/10%/$100 ded/30%/50%, $2000 OOP, Prescription Vision: No co‐pay on annual exam, $150 hardware every 24 months EMPLOYEE 818.37 654.70 300‐1 EMPLOYEE & SPOUSE 1,491.21 1,031.49 300‐2 EMPLOYEE & CHILDREN 1,323.00 937.29 300‐3 EMPLOYEE & FAMILY 1,995.84 1,314.08 300‐4 HEALTH SAVINGS ACCOUNT (HSA) & VISION PLANS Must Pay ALL of Ded 1st, then pays 15%/40% of medical, hospital, emergency room, prescriptions until total out of pocket is met. $1400 ind/$2800 fam ded, plus $4200/$8400 out of pocket max, 306‐1 5%/10%/$100 ded/30%/50%, $2000 OOP, Prescription Vision: No co‐pay on annual exam, $150 hardware every 24 months Contribution Limits: Under 55‐$3450 ind/$6900 fam. Over 55: $4450 ind/$7,900 fam EMPLOYEE 749.42 654.70 0.00 94.72 301‐1 EMPLOYEE & SPOUSE 1,347.34 1,031.49 0.00 315.85 301‐2 EMPLOYEE & CHILDREN 1,212.44 937.29 0.00 275.15 301‐3 EMPLOYEE & FAMILY 1,752.03 1,314.08 0.00 437.95 301‐4 145.53 302‐1 25.00 302‐90 50.00 302‐91 1) Uniform Dental Plan (Group 3000) or $50 deductible in‐network, 100% Preventive, $1750 annual max, 80% basic, 50% major, adult & child orthodontia EMPLOYEE 0.00 0.00 EMPLOYEE & SPOUSE 0.00 0.00 EMPLOYEE & CHILDREN 0.00 0.00 EMPLOYEE & FAMILY 0.00 0.00 2) WILLAMETTE or IN NETWORK ONLY ‐ Managed Care Plans, Set Rates & No Max Benefit PREMIUM County Pays EMPLOYEE 0.00 0.00 EMPLOYEE & SPOUSE 0.00 0.00 EMPLOYEE & CHILDREN 0.00 0.00 EMPLOYEE & FAMILY 0.00 0.00 LIFE INSURANCE & AD & D Life & LTD Only Applicable only IF enrolled in Medical PREMIUM County Pays Employee $35,000 & Additional $5000 for accidental death 0.00 0.00 X LONG TERM DISABILITY (LTD) ‐ Standard Insurance Co. 0.00 0.00 X Mark DC Flexible Spending Account (FSA), Max $2,600 ‐ Plus Point FSA/DCR Fee $5.00 92‐95 $ 92‐5 Dependent Care Reimbursement (DCR) Max $2,500/$5,000 ‐ Plus Point 92‐15 Voluntary Long Term Disability Plan (Income protection if disable) 316‐1 VOLUNTARY TAX SAVING PLANS OR ADDITIONAL INSURANCE SELECTION Amount All Self‐ Paid $ All Self‐ Paid MARK ONE EMPLOYEE PAYS 0.00 0.00 After 90 days being disabled, 60% of 1st $400 of current earnings. Min $50 & Max $240 per month EMPLOYEE PAYS 0.00 0.00 0.00 0.00 MetLife ‐ Life Ins & Standard ‐ LTD 0.00 0.00 0.00 MARK ONE 3) DELTA CARE (Group 3100) Administered by Delta Dental Tobacco Surcharge: If you, or a dependent covered by the plan, use tobacco products Spouse or Dom. Partner Coverage Surcharge (go to Spousal Plan Calculator on the web) Dental Plans You May Select One of the Following (place in small box) Employees can place dep on dental plans, without placing on medical. C h o o s e O n e P l a n PREMIUM COUNTY PAYS EMPLOYEE PAYS or, MARK ONE 0.00 Emp HSA Contribution: $ PREMIUM COUNTY PAYS COUNTY PAYS TO HSA 305‐1 EMPLOYEE PAYS MARK ONE Ded Code 163.67 459.72 385.71 681.76 UMP Consumer‐Directed Health Plan (CDHP) (HSA) ‐ Premium Includes: Dental, Vision, Basic Life Insurance & EE LTD Coverage‐Regence MARK IF CONTRIB. TO HSA County contributes 100% for Employee Medical, Dental, Vision, Life Insurance & LTD & 70% of the Additional Cost for Dependent Medical, Dental, Vision, Life Ins & LTD Coverage (County Pays an Avg of 86% for Dep) C h o o s e O n e P l a n Uniform Medical Plan (UMP) ‐ Classic Premium Includes: Dental, Vision, Life Insurance & EE LTD Coverage ‐ Administered by Regence MARK ONE Ded Code PREMIUM COUNTY PAYS EMPLOYEE PAYS Waiver Fee: If you waive medical, you must be on dental, life & LTD Selection Sheet for PEBB Insurance Deductions - Klickitat County .8 FTE/32 hr per week - Effective January 1, 2018, premiums reflected on your Dec. 25th payroll check Go to the Web - Health Care Authority, Public Employees Benefits Board, for Benefit Descriptions at: www.hca.wa.gov/pebb Print Last Name: Emp No: Signature: Date: I hereby authorize the deductions below and acknowledge that I have been informed of my COBRA rights. ---PAGE BREAK--- MEDICAL & VISION PLANS $250 ind/$750 fam ded, plus $2000 ind/$4000 fam out of pocket max, 15% office visit co‐pay, 15%/40% hospital co‐insurance 5%/10%/$100 ded/30%/50%, $2000 OOP, Prescription Vision: No co‐pay on annual exam, $150 hardware every 24 months EMPLOYEE 818.37 613.78 300‐1 EMPLOYEE & SPOUSE 1,491.21 967.02 300‐2 EMPLOYEE & CHILDREN 1,323.00 878.71 300‐3 EMPLOYEE & FAMILY 1,995.84 1,231.95 300‐4 HEALTH SAVINGS ACCOUNT (HSA) & VISION PLANS Must Pay ALL of Ded 1st, then pays 15%/40% of medical, hospital, emergency room, prescriptions until total out of pocket is met. $1400 ind/$2800 fam ded, plus $4200/$8400 out of pocket max, 306‐1 5%/10%/$100 ded/30%/50%, $2000 OOP, Prescription Vision: No co‐pay on annual exam, $150 hardware every 24 months Contribution Limits: Under 55‐$3450 ind/$6900 fam. Over 55: $4450 ind/$7,900 fam EMPLOYEE 749.42 613.78 0.00 135.64 301‐1 EMPLOYEE & SPOUSE 1,347.34 967.02 0.00 380.32 301‐2 EMPLOYEE & CHILDREN 1,212.44 878.71 0.00 333.73 301‐3 EMPLOYEE & FAMILY 1,752.03 1,231.95 0.00 520.08 301‐4 145.53 302‐1 25.00 302‐90 50.00 302‐91 1) Uniform Dental Plan (Group 3000) or $50 deductible in‐network, 100% Preventive, $1750 annual max, 80% basic, 50% major, adult & child orthodontia EMPLOYEE 0.00 0.00 EMPLOYEE & SPOUSE 0.00 0.00 EMPLOYEE & CHILDREN 0.00 0.00 EMPLOYEE & FAMILY 0.00 0.00 2) WILLAMETTE or IN NETWORK ONLY ‐ Managed Care Plans, Set Rates & No Max Benefit PREMIUM County Pays EMPLOYEE 0.00 0.00 EMPLOYEE & SPOUSE 0.00 0.00 EMPLOYEE & CHILDREN 0.00 0.00 EMPLOYEE & FAMILY 0.00 0.00 LIFE INSURANCE & AD & D Life & LTD Only Applicable only IF enrolled in Medical PREMIUM County Pays Employee $35,000 & Additional $5000 for accidental death 0.00 0.00 X LONG TERM DISABILITY (LTD) ‐ Standard Insurance Co. 0.00 0.00 X Mark DC Flexible Spending Account (FSA), Max $2,600 ‐ Plus Point FSA/DCR Fee $5.00 92‐95 $ 92‐5 Dependent Care Reimbursement (DCR) Max $2,500/$5,000 ‐ Plus Point 92‐15 Voluntary Long Term Disability Plan (Income protection if disable) 316‐1 VOLUNTARY TAX SAVING PLANS OR ADDITIONAL INSURANCE SELECTION Amount All Self‐ Paid $ All Self‐ Paid MARK ONE 0.00 After 90 days being disabled, 60% of 1st $400 of current earnings. Min $50 & Max $240 per month 0.00 0.00 0.00 0.00 MetLife ‐ Life Ins & Standard ‐ LTD 0.00 0.00 0.00 0.00 3) DELTA CARE (Group 3100) EMPLOYEE PAYS EMPLOYEE PAYS 0.00 Tobacco Surcharge: If you, or a dependent covered by the plan, use tobacco products Spouse or Dom. Partner Coverage Surcharge (go to Spousal Plan Calculator on the web) Dental Plans You May Select One of the Following (place in small box) Employees can place dep on dental plans, without placing on medical. C h o o s e O n e P l a n PREMIUM COUNTY PAYS EMPLOYEE PAYS or, MARK ONE MARK ONE MARK IF CONTRIB. TO HSA Emp HSA Contribution: $ PREMIUM COUNTY PAYS COUNTY PAYS TO HSA 305‐1 EMPLOYEE PAYS MARK ONE Ded Code EMPLOYEE PAYS 204.59 524.19 444.29 763.89 UMP Consumer‐Directed Health Plan (CDHP) (HSA) ‐ Premium Includes: Dental, Vision, Basic Life Insurance & EE LTD Coverage‐Regence I hereby authorize the deductions below and acknowledge that I have been informed of my COBRA rights. County contributes 100% for Employee Medical, Dental, Vision, Life Insurance & LTD & 70% of the Additional Cost for Dependent Medical, Dental, Vision, Life Ins & LTD Coverage (County Pays an Avg of 86% for Dep) C h o o s e O n e P l a n Uniform Medical Plan (UMP) ‐ Classic Premium Includes: Dental, Vision, Life Insurance & EE LTD Coverage ‐ Administered by Regence MARK ONE Ded Code PREMIUM COUNTY PAYS Administered by Delta Dental Waiver Fee: If you waive medical, you must be on dental, life & LTD Selection Sheet for PEBB Insurance Deductions - Klickitat County .75 FTE/30 hr per week - Effective January 1, 2018, premiums reflected on your Dec. 25th payroll check Go to the Web - Health Care Authority, Public Employees Benefits Board, for Benefit Descriptions at: www.hca.wa.gov/pebb Print Last Name: Emp No: Signature: Date: ---PAGE BREAK--- MEDICAL & VISION PLANS $250 ind/$750 fam ded, plus $2000 ind/$4000 fam out of pocket max, 15% office visit co‐pay, 15%/40% hospital co‐insurance 5%/10%/$100 ded/30%/50%, $2000 OOP, Prescription Vision: No co‐pay on annual exam, $150 hardware every 24 months EMPLOYEE 818.37 572.86 300‐1 EMPLOYEE & SPOUSE 1,491.21 902.55 300‐2 EMPLOYEE & CHILDREN 1,323.00 820.13 300‐3 EMPLOYEE & FAMILY 1,995.84 1,149.82 300‐4 HEALTH SAVINGS ACCOUNT (HSA) & VISION PLANS Must Pay ALL of Ded 1st, then pays 15%/40% of medical, hospital, emergency room, prescriptions until total out of pocket is met. $1400 ind/$2800 fam ded, plus $4200/$8400 out of pocket max, 306‐1 5%/10%/$100 ded/30%/50%, $2000 OOP, Prescription Vision: No co‐pay on annual exam, $150 hardware every 24 months Contribution Limits: Under 55‐$3450 ind/$6900 fam. Over 55: $4450 ind/$7,900 fam EMPLOYEE 749.42 572.86 0.00 176.56 301‐1 EMPLOYEE & SPOUSE 1,347.34 902.55 0.00 444.79 301‐2 EMPLOYEE & CHILDREN 1,212.44 820.13 0.00 392.31 301‐3 EMPLOYEE & FAMILY 1,752.03 1,149.82 0.00 602.21 301‐4 145.53 302‐1 25.00 302‐90 50.00 302‐91 1) Uniform Dental Plan (Group 3000) or $50 deductible in‐network, 100% Preventive, $1750 annual max, 80% basic, 50% major, adult & child orthodontia EMPLOYEE 0.00 0.00 EMPLOYEE & SPOUSE 0.00 0.00 EMPLOYEE & CHILDREN 0.00 0.00 EMPLOYEE & FAMILY 0.00 0.00 2) WILLAMETTE or IN NETWORK ONLY ‐ Managed Care Plans, Set Rates & No Max Benefit PREMIUM County Pays EMPLOYEE 0.00 0.00 EMPLOYEE & SPOUSE 0.00 0.00 EMPLOYEE & CHILDREN 0.00 0.00 EMPLOYEE & FAMILY 0.00 0.00 LIFE INSURANCE & AD & D Life & LTD Only Applicable only IF enrolled in Medical PREMIUM County Pays Employee $35,000 & Additional $5000 for accidental death 0.00 0.00 X LONG TERM DISABILITY (LTD) ‐ Standard Insurance Co. 0.00 0.00 X Mark DC Flexible Spending Account (FSA), Max $2,600 ‐ Plus Point FSA/DCR Fee $5.00 92‐95 $ 92‐5 Dependent Care Reimbursement (DCR) Max $2,500/$5,000 ‐ Plus Point 92‐15 Voluntary Long Term Disability Plan (Income protection if disable) 316‐1 VOLUNTARY TAX SAVING PLANS OR ADDITIONAL INSURANCE SELECTION Amount All Self‐ Paid $ All Self‐ Paid 0.00 0.00 After 90 days being disabled, 60% of 1st $400 of current earnings. Min $50 & Max $240 per month 0.00 0.00 0.00 0.00 MetLife ‐ Life Ins & Standard ‐ LTD MARK ONE 0.00 0.00 MARK ONE 3) DELTA CARE (Group 3100) EMPLOYEE PAYS Administered by Delta Dental EMPLOYEE PAYS Tobacco Surcharge: If you, or a dependent covered by the plan, use tobacco products Spouse or Dom. Partner Coverage Surcharge (go to Spousal Plan Calculator on the web) Dental Plans You May Select One of the Following (place in small box) Employees can place dep on dental plans, without placing on medical. C h o o s e O n e P l a n PREMIUM COUNTY PAYS EMPLOYEE PAYS or, MARK ONE 0.00 0.00 Emp HSA Contribution: $ PREMIUM COUNTY PAYS COUNTY PAYS TO HSA 305‐1 EMPLOYEE PAYS MARK ONE Ded Code 245.51 588.66 502.87 846.02 UMP Consumer‐Directed Health Plan (CDHP) (HSA) ‐ Premium Includes: Dental, Vision, Basic Life Insurance & EE LTD Coverage‐Regence MARK IF CONTRIB. TO HSA County contributes 100% for Employee Medical, Dental, Vision, Life Insurance & LTD & 70% of the Additional Cost for Dependent Medical, Dental, Vision, Life Ins & LTD Coverage (County Pays an Avg of 86% for Dep) C h o o s e O n e P l a n Uniform Medical Plan (UMP) ‐ Classic Premium Includes: Dental, Vision, Life Insurance & EE LTD Coverage ‐ Administered by Regence MARK ONE Ded Code PREMIUM COUNTY PAYS EMPLOYEE PAYS Waiver Fee: If you waive medical, you must be on dental, life & LTD Selection Sheet for PEBB Insurance Deductions - Klickitat County .7 FTE/28 hr per week - Effective January 1, 2018, premiums reflected on your Dec. 25th payroll check Go to the Web - Health Care Authority, Public Employees Benefits Board, for Benefit Descriptions at: www.hca.wa.gov/pebb Print Last Name: Emp No: Signature: Date: I hereby authorize the deductions below and acknowledge that I have been informed of my COBRA rights. ---PAGE BREAK--- MEDICAL & VISION PLANS $250 ind/$750 fam ded, plus $2000 ind/$4000 fam out of pocket max, 15% office visit co‐pay, 15%/40% hospital co‐insurance 5%/10%/$100 ded/30%/50%, $2000 OOP, Prescription Vision: No co‐pay on annual exam, $150 hardware every 24 months EMPLOYEE 818.37 491.02 300‐1 EMPLOYEE & SPOUSE 1,491.21 773.62 300‐2 EMPLOYEE & CHILDREN 1,323.00 702.97 300‐3 EMPLOYEE & FAMILY 1,995.84 985.56 300‐4 HEALTH SAVINGS ACCOUNT (HSA) & VISION PLANS Must Pay ALL of Ded 1st, then pays 15%/40% of medical, hospital, emergency room, prescriptions until total out of pocket is met. $1400 ind/$2800 fam ded, plus $4200/$8400 out of pocket max, 306‐1 5%/10%/$100 ded/30%/50%, $2000 OOP, Prescription Vision: No co‐pay on annual exam, $150 hardware every 24 months Contribution Limits: Under 55‐$3450 ind/$6900 fam. Over 55: $4450 ind/$7,900 fam EMPLOYEE 749.42 491.02 0.00 258.40 301‐1 EMPLOYEE & SPOUSE 1,347.34 773.62 0.00 573.72 301‐2 EMPLOYEE & CHILDREN 1,212.44 702.97 0.00 509.47 301‐3 EMPLOYEE & FAMILY 1,752.03 985.56 0.00 766.47 301‐4 145.53 302‐1 25.00 302‐90 50.00 302‐91 1) Uniform Dental Plan (Group 3000) or $50 deductible in‐network, 100% Preventive, $1750 annual max, 80% basic, 50% major, adult & child orthodontia EMPLOYEE 0.00 0.00 EMPLOYEE & SPOUSE 0.00 0.00 EMPLOYEE & CHILDREN 0.00 0.00 EMPLOYEE & FAMILY 0.00 0.00 2) WILLAMETTE or IN NETWORK ONLY ‐ Managed Care Plans, Set Rates & No Max Benefit PREMIUM County Pays EMPLOYEE 0.00 0.00 EMPLOYEE & SPOUSE 0.00 0.00 EMPLOYEE & CHILDREN 0.00 0.00 EMPLOYEE & FAMILY 0.00 0.00 LIFE INSURANCE & AD & D Life & LTD Only Applicable only IF enrolled in Medical PREMIUM County Pays Employee $35,000 & Additional $5000 for accidental death 0.00 0.00 X LONG TERM DISABILITY (LTD) ‐ Standard Insurance Co. 0.00 0.00 X Mark DC Flexible Spending Account (FSA), Max $2,600 ‐ Plus Point FSA/DCR Fee $5.00 92‐95 $ 92‐5 Dependent Care Reimbursement (DCR) Max $2,500/$5,000 ‐ Plus Point 92‐15 Voluntary Long Term Disability Plan (Income protection if disable) 316‐1 All Self‐ Paid 0.00 After 90 days being disabled, 60% of 1st $400 of current earnings. Min $50 & Max $240 per month VOLUNTARY TAX SAVING PLANS OR ADDITIONAL INSURANCE SELECTION Amount All Self‐ Paid $ EMPLOYEE PAYS 0.00 0.00 0.00 0.00 0.00 0.00 MetLife ‐ Life Ins & Standard ‐ LTD 3) DELTA CARE (Group 3100) EMPLOYEE PAYS 0.00 0.00 Administered by Delta Dental or, MARK ONE MARK ONE Tobacco Surcharge: If you, or a dependent covered by the plan, use tobacco products Spouse or Dom. Partner Coverage Surcharge (go to Spousal Plan Calculator on the web) Dental Plans You May Select One of the Following (place in small box) Employees can place dep on dental plans, without placing on medical. C h o o s e O n e P l a n PREMIUM COUNTY PAYS EMPLOYEE PAYS 0.00 MARK ONE Emp HSA Contribution: $ PREMIUM COUNTY PAYS COUNTY PAYS TO HSA 305‐1 EMPLOYEE PAYS MARK ONE Ded Code 327.35 717.59 620.03 1,010.28 UMP Consumer‐Directed Health Plan (CDHP) (HSA) ‐ Premium Includes: Dental, Vision, Basic Life Insurance & EE LTD Coverage‐Regence MARK IF CONTRIB. TO HSA County contributes 100% for Employee Medical, Dental, Vision, Life Insurance & LTD & 70% of the Additional Cost for Dependent Medical, Dental, Vision, Life Ins & LTD Coverage (County Pays an Avg of 86% for Dep) C h o o s e O n e P l a n Uniform Medical Plan (UMP) ‐ Classic Premium Includes: Dental, Vision, Life Insurance & EE LTD Coverage ‐ Administered by Regence MARK ONE Ded Code PREMIUM COUNTY PAYS EMPLOYEE PAYS Waiver Fee: If you waive medical, you must be on dental, life & LTD Selection Sheet for PEBB Insurance Deductions - Klickitat County .6 FTE/24 hr per week - Effective January 1, 2018, premiums reflected on your Dec. 25th payroll check Go to the Web - Health Care Authority, Public Employees Benefits Board, for Benefit Descriptions at: www.hca.wa.gov/pebb Print Last Name: Emp No: Signature: Date: I hereby authorize the deductions below and acknowledge that I have been informed of my COBRA rights. ---PAGE BREAK---