Plan Costs
Medical Plan 1
Employee Only: $XX
Employee and Spouse: $XX
Employee and Child(ren): $XX
Employee and Family: $XX
Medical Plan 2
Employee Only: $XX
Employee and Spouse: $XX
Employee and Child(ren): $XX
Employee and Family: $XX
Medical Plan 3
Employee Only: $XX
Employee and Spouse: $XX
Employee and Child(ren): $XX
Employee and Family: $XX
Dental Plan 1
Employee Only: $XX
Employee and Spouse: $XX
Employee and Child(ren): $XX
Employee and Family: $XX
Dental Plan 2
Employee Only: $XX
Employee and Spouse: $XX
Employee and Child(ren): $XX
Employee and Family: $XX
Vision Plan
Employee Only: $XX
Employee and Spouse: $XX
Employee and Child(ren): $XX
Employee and Family: $XX
Domestic Partner Coverage
Please note that unless your domestic partner is your tax dependent as defined by the IRS, contributions for domestic partner coverage must be made after-tax. Similarly, the company contribution toward coverage for your domestic partner and his/her dependents will be reported as taxable income on your W-2. Contact your tax advisor for more details on how this tax treatment applies to you. Notify [Company] if your domestic partner is your tax dependent.