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BENSSCNF_MMI1992868774_out - Banfield Pet Hospital 18101 SE...

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Banfield Pet Hospital18101 SE 6thWayVancouver, WA 986831This benefit does not apply to Puerto Rico associates. Participation and prefunds will vary by Charter locations.____________________________________________________________________________________________________________Benefits Confirmation & SummaryLouhidon, Sualen2000 Madison St#1Hollywood, FL, 33020Dear Sualen Louhidon,This benefit confirmation statement provides you a summary of your benefit elections and associated costs (as applicable). Thebenefits you elected may be taken as pre or post-tax payroll deductions depending on the benefit options available to you. Please seebelow for a breakdown of your payroll deductions. NOTE: IRS regulations state you may not make changes to your benefits during theremainder of the plan year unless you experience a qualifying life event; without a qualifying life event, your next opportunity to makechanges will be during Open Enrollment. More information on qualifying life events is provided in the Benefits Guide.Suspended Elections, Interim Coverage & Action ItemsSuspendedInterim CoverageAction ItemDue DateHealth Savings Account - enrollmentincludes an annual pre-fund of $750.00 Flat Amount - SingleEnrollment Certification RequiredBenefits SelectionsThe following benefits elections were chosen by you.PlanOptionCoverageCoverageStart DateYou Pay Before TaxYou Pay After TaxBanfield PaysLink to - Benefits Guide Practice Full Time Information06-Jun-20160.000.000.00Link to - Principal 401K Enrollment Information01-Sep-20160.000.000.00Medical - Consumer Select PPO Medical Plan Assoc Only01-Sep-201619.680.00358.34HSA - Health Savings Account - enrollment includes an annual pre-fund of $750.00 (Suspended)Flat Amount - Single400.0001-Sep-201650.000.000.00HSA Disqualification Disclaimer - Are you participating in another health plan or Flex Spending Account? No01-Sep-20160.000.000.00Health Care Flexible Spending Account - Decline Health Care FSA and Limited-Use FSA Plans Decline01-Sep-20160.000.000.00Dental - PPO Dental Plan Assoc Only01-Sep-201611.460.007.64Vision - Vision Service Plan Assoc Only01-Sep-20163.170.000.00Practice Paid Life Insurance- Practice Basic Group Life 3 x Annual Salary72,000.0001-Sep-20160.000.004.54Assoc Additional Life Insurance - UNUM Assoc Additional Life Insurance

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Term
Spring
Professor
Irina Shusterman
Tags
Health savings account, Flexible spending account, Banfield, Puerto Rico Associates, Banfield Pet Hospital, post tax payroll deductions

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