BConnected - Confirmation Statement

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BConnected Event Date: Feb 4, 2013 | Enrollment Deadline: Mar 11, 2013 | Days Left: 8 Confirmation Number: 13037200254 Confirmed on: Mar 4, 2013 03:23 PM EST Print Page | Back

Your coverage has been updated. Review this confirmation carefully to make sure you have the coverage you want and your dependent information is accurate.
Print and keep this confirmation for your records. For future inquiries, refer to the confirmation number above. To receive a paper confirmation statement in the mail, call (800) 566-4114. If you enrolled a new dependent in health and group coverage, additional information will be mailed to the address you have on file. Be sure to submit any required documentation prior to the deadline listed on your notice or the applicable dependents will be dropped from coverage. To track your dependents, click My Health Benefits, and then Track My Newly Added Dependents. IMPORTANT: You can go back and update your coverage elections as many times as you want, as long as the enrollment period hasn't ended. To update your coverage now, click the Enroll in Benefits link in the Follow These Steps box to the right.

https://hcarewards.lifeatworkportal.com/benefitsweb/html/HW/reviewSummary.jsp?URID_... 3/4/2013

BConnected - Confirmation Statement

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Coverage Overview Benefit Medical Dental Health Care Flexible Spending Account Dependent Life Insurance Vision Coverage Effective Date Per-Pay-Period Contribution $119.27 $41.45 $19.23 $1.54 $6.23 $0.00 $0.00 $0.00 $187.72

Well Care Level 1 , Employee + 3 or 03/06/2013 More Delta Dental - Idaho Falls , Employee + 3 or More Annual Contribution: $500.00 $10,000 each , for all covered dependents Vision Coverage , Employee + 2 03/06/2013 03/06/2013 03/06/2013 03/06/2013 03/06/2013 02/04/2013 03/06/2013

CorePlus Voluntary Life with Long-Term Care No Coverage Conversion Option Employee Assistance Program Behavioral Health Plan Total ValueOptions - Currently Covered ValueOptions - Currently Covered

Covered Dependents Name EMILY F WARD Social Security No. XXX-XX-4227 Birth Date 05/17/1976 Gender Female Relationship Spouse Coverage Medical Dental Dependent Life Vision Medical Dental Vision Medical Dental Medical Dental Medical Dental

AUSTIN MICHEAL WARD HAILEE RENEE WARD JAYDON MISKIN WARD ASHLYN FAYE WARD

XXX-XX-6617 XXX-XX-1704 XXX-XX-9509 XXX-XX-0132

05/24/2002 07/24/2004 05/12/2006 06/04/2008

Male Female Male Female

Child Child Child Child

IMPORTANT: The per-pay-period amount displayed for your Health Care Flexible Spending Account represents your annual goal divided by your number of pay cycles in a year (12, 26 or 52). If you've been on an unpaid leave of absence or if you made a mid-year election or change, your actual per-pay-period payroll deduction will be different from the amount shown. Print Page | Back

https://hcarewards.lifeatworkportal.com/benefitsweb/html/HW/reviewSummary.jsp?URID_... 3/4/2013