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Open Enrollment Event       Event Summary          Select Benefits  Sign Up  Confirm Enrollment   Exit Event   Please review all your information before you Confirm. If you wish to make changes, click one of the links below. When you're confident all information is correct, click on Confirm. Your information will not be submitted unless you click on Confirm.   Event Summary   Policy Period Benefit Plan Selection Weekly Bi-weekly Monthly Annual Semi-monthly   01/01/2007-12/31/2007 Medical HRA Choice Fund, Employee + Family $130.93 01/01/2007-12/31/2007 Dental PPO Standard Dental, Employee + One $20.00 01/01/2007-12/31/2007 Flexible Spending Health Care Reimbursement Account, $2,400 $200.00 Dependent Care Reimbursement Account, $3,600 $300.00 01/01/2007-12/31/2007 Disability Short Term Disability, $30,000 $2.17 Long Term Disability, $18,000 $1.03 01/01/2007-12/31/2007 Life Insurance Basic Life Insurance, 1X Salary $0.00 Supplemental Life Insurance, 2X Salary $0.89 Spouse - Dependent Life Insurance, $50,000 $1.11   Your Total Cost   $656.13   Covered Members Relationship Coverage Elections Doctor Selected   Jack Smith Self Medical, Dental, FSA, Disability, Life Paul Ashcroft Jane Smith Spouse Medical, Dental Amy Scott Josh Smith Child Medical Paul Ashcroft   By confirming the coverage selections for my listed dependents and myself, I agree to the following: My pay will automatically be reduced in the manner set in the Plan Summary by the amount of any required contributions for the Plan; Elections under the Plan can be changed or revoked by me only at each annual enrollment, on account of, and consistent with a change in my family status (as defined under the Plan), or as otherwise permitted under Federal law; The information I have furnished, to the best of my knowledge and belief, is correct and complete; I understand it is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. In the event it is determined that information I provided is fraudulent and claims were paid using that fraudulent information, my employer will be authorized to recover the costs paid through payroll deduction; I understand all benefits are subject to conditions stated in the group agreement and Certificate of Coverage. Please remember your information will not be submitted unless you click on Confirm. Legal Disclaimer,  Privacy Policy, (06/10/2006) Copyright© 2000-2006 Choicelinx Corporation. All rights reserved.