| Active Employees - Medical and $10,000 Life/AD&D Insurance ONLY |
| Medical Plan |
Employee
Only |
Employee
+1 Dep |
Family |
Employee
Only |
Employee
+1 Dep |
Family |
Total |
|
Blue Shield - High Option PPO
|
|
|
|
$- |
$- |
$- |
$- |
| |
| Blue Shield - $1,500 Deductible |
|
|
|
$- |
$- |
$- |
$- |
| Blue Shield HMO |
|
|
|
$- |
$- |
$- |
$- |
| Northern California Kaiser |
|
|
|
$- |
$- |
$- |
$- |
| Southern California Kaiser |
|
|
|
$- |
$- |
$- |
$- |
| Sub-Total Medical & Life/AD & D |
0 |
0 |
0 |
$- |
$- |
$- |
$- |
| |
| 1) Would you like to add dental coverage? |
yes
no
|
|
$- |
|
$71.20 per single employee, $126.56 per 2-Party employee, $209.61 per Family employee. |
| |
| 2) Would you like to add vision coverage? |
yes
no
|
|
$- |
|
$7.80 per single employee, $12.12 per 2-Party employee, $19.23 per Family employee. |
| |
| Monthly Billing Rate for Active Employees |
$- |
|
| |
| Early Retirees - Medical ONLY |
| Medical Plan |
Employee
Only |
Employee
+1 Dep |
Family |
Employee
Only |
Employee
+1 Dep |
Family |
Total |
|
Blue Shield - High Option PPO |
|
|
|
$- |
$- |
$- |
$- |
| Blue Shield - $1,500 Deductible |
|
|
|
$- |
$- |
$- |
$- |
| Blue Shield - HMO |
|
|
|
$- |
$- |
$- |
$- |
| Northern California Kaiser |
|
|
|
$- |
$- |
$- |
$- |
| Southern California Kaiser |
|
|
|
$- |
$- |
$- |
$- |
| Sub-Total Medical ONLY |
0 |
0 |
0 |
$- |
$- |
$- |
$- |
| |
| 1) Would you like to add dental coverage? |
yes
no
|
|
$- |
|
$71.20 per single employee, $126.56 per 2-Party employee, $209.61 per Family employee. |
| |
| 2) Would you like to add vision coverage? |
yes
no
|
|
$- |
|
$7.80 per single employee, $12.12 per 2-Party employee, $19.23 per Family employee. |
| |
| Monthly Billing Rate for Early Retirees |
$- |
|
| |
| Retirees - Medical ONLY |
| Medical Plan |
Employee
Only |
Employee
+1 Dep |
Family |
Employee
Only |
Employee
+1 Dep |
Family |
Total |
| Blue Shield - High Option |
|
|
|
$- |
$- |
$- |
$- |
| Blue Shield - HMO |
|
|
|
$- |
$- |
$- |
$- |
| Nothern California Kaiser Medicare Risk |
|
|
|
$- |
$- |
$- |
$- |
| Southern California Kaiser Medicare Risk |
|
|
|
$- |
$- |
$- |
$- |
| Sub-Total Medical &Life/AD & D |
0 |
0 |
0 |
$- |
$- |
$- |
$- |
| |
| 1) Would you like to add dental coverage? |
yes
no
|
|
$- |
|
$71.20 per single employee, $126.56 per 2-Party employee, $209.61 per Family employee. |
| |
| 2) Would you like to add vision coverage? |
yes
no
|
|
$- |
|
$7.80 per single employee, $12.12 per 2-Party employee, $19.23 per Family employee. |
| |
| Monthly Billing Rate for Retirees |
$- |
|
| |
| Total Employees |
0 |
| Total Monthly Billing |
$- |