Health insurance change

Email *

Employee Name *

First

Last

Your Date of Birth *

We currently offere two plans for our employees to choose from that we offer at a hugely discounted rate. For details about these plans please visit our BENEFITS page

Highmark Plans *

Employee Add-ons

Dental
Vision

Will you be adding a Spouse?

Spouse's Date of Birth

Spouse's Age

Coverages that Spouse will be enrolled in

Medical
Dental
Vision

Cost Total for spouse

Per Week

$0.00

Per Month

$0.00

Per Year

$0.00

Will you adding any dependents?

How many dependents would you like to add?

in per

Dependent Date of Birth

Dependent's Age

Dependent will be enrolled in

Medical
Dental
Vision

Dependent Cost per Week

$0.00

Dependent-2 Date of Birth

Dependent-2's Age

Dependent-2 will be enrolled in

Medical
Dental
Vision

Dependent-2 Cost per Week

$0.00

Dependent-3 Date of Birth

Dependent-3's Age

Dependent-3 will be enrolled in

Medical
Dental
Vision

Dependent-3 Cost per Week

$0.00

Dependent-4 Date of Birth

Dependent-4's Age

Dependent-4 will be enrolled in

Medical
Dental
Vision

Dependent-4 Cost per Week

$0.00

Dependent-5 Date of Birth

Dependent-5's Age

Dependent-5 will be enrolled in

Medical
Dental
Vision

Dependent-5 Cost per Week

$0.00

Dependent-6 Date of Birth

Dependent-6's Age

Dependent-6 will be enrolled in

Medical
Dental
Vision

Dependent-6 Cost per Week

$0.00

Plan total cost for all selected members

Per Week

$0.00

Per Month

$0.00

Per Year

$0.00

I, *

would like to change my benefits package to reflect what has been entered into this calculator.

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