Submit Elections Confirmation
06:00 AM03/24/2014Page 1 of 2
Hire for Bush, SamanthaMiriam ValtierraInitiated On:02/27/2014Submit Elections By:03/19/2014Event Date:02/17/2014$115.66 Monthly CostTotal Employee Cost/Credit
Benefit PlanCoverageBegin DateDeductionBegin DateCoverageCalculatedCoverageDependentsBeneficiariesEmployeeCost (Monthly)Employer Contribution (Monthly)MNG Medical - Kaiser DHMO05/01/201405/01/2014EmployeeOnly$115.66$269.90MNG Basic Life/AD&D- Cigna - 50k Max(Employee)05/01/201405/01/20141 X Salary$39,000.00$4.45Total:$115.66$274.35
Plan TypeMNG DentalMNG VisionMNG Health Savings AccountHealthcare FSADependent Care FSAParking SACommuter SAMNG Supp Life/AD&DMNG Supp Life/AD&D SpouseMNG Supp Life ChildMNG Voluntary LTD
Benefit PlanRequires BeneficiaryBeneficiariesMNG Basic Life/AD&D - Cigna - 50k Max (Employee)Electronic SignatureBy clicking ‘AGREE’, I affirm that all information I have provided is full, complete and true to the best of my knowledge, and I authorizedeductions and required contributions to be taken from my pay on a pre or post tax basis, as appropriate, to implement my benefitelections. I understand that a change in coverage must be due to and consistent with a change in family status as permitted by applicablelaw and regulations. Examples of such change in family status include marriage, divorce, death of a spouse or child, birth or adoption of a child or termination of employment of spouse.
Change in enrollment must be made within 31 days of any qualifying event by the employee through their Workday self-service account