Benefit Election Form

If you have met the definition of Full-time employee under the ACA guidelines, you may be determined to be eligible for health benefits, below you will find a short summary of your benefit plan coverage and projected cost.

Benefits Network Single/Family
Office Copay (PCP/SPC) Subject to Deductible & Coinsurance
Hospital Copays Subject to Deductible & Coinsurance
UC/ER/Major Diag Copay Subject to Deductible & Coinsurance
Other N/A
Deductible $5,000/10,000 (NonEmb)
Coinsurance 100%
Out-of-Pocket $6,350/12,700
Pharmacy Int Med/Rx Ded; $20/40/70

Your cost for employee only coverage will vary based on your individual hourly pay rates and number of hours worked and is calculated at 9.5% of your gross income deducted after taxes.  Below you will find numerous examples of projected costs for employee only benefits:

Example chart for various pay rates

Hourly Rate Yearly Cost Monthly Cost Weekly Cost Hours Worked in Month
$20.00 $3,944.40 $328.70 $75.85 173
$15.00 $3,078.00 $256.50 $59.19 180
$13.00 $3,186.24 $265.52 $61.27 215
$11.00 $2,193.00 $182.75 $42.17 175
$9.00 $1,282.44 $106.87 $24.66 125

*The example rates shown above are for employee only single coverage. If you intend to cover your children dependents as well under this health plan, you will be responsible for an additional $3,899.52 annually, $324.96 Per Month, $74.99 per week.*

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You must opt in, or opt out of this program at this time, please complete all of the information on the form below to make your selection, then click the Submit button.

Please complete the following information:

Your First Name:
Your Last Name:
Street Address:
City/State/Zip:
Email Address:
Phone Number:
Gender (for government census reporting):

Please make your selection here to opt in or out:

Electronic Signature:
Today's Date (yyyy/mm/dd):
I understand that my electronic signature and selection is final and if I select to 'Opt-In' to benefits I am required to complete enrollment forms and submit them to PeopleShare’s outsourced benefit manager within 7 days or I will be considered as having “opted-out” of benefit coverage.


Click Submit to send your election information to PeopleShare.

If you chose to OPT IN, please click here to to complete your Enrollment Form.