Health Care Costs per Employee per Month for the Calendar Year of: _________

(Formulas are included)

Medical Insurance Dental Insurance Any Other
Premiums Paid Premiums Paid Health Care
by Employer by Employer Costs Paid
by Employer

January
February
March
April
May
June
July
August
September
October
November
December

ANNUAL (uses average numbe $0 $0 $0

_________

Total Health Total Number Total Health

Care Costs of Employees Care Costs
Paid by Paid by
Employer Employer
per Employee

$0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!

$0 0.0 #DIV/0!