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Confirmation Statement for CYNTHIA HEWATT Submitted on 11/11/2014 08:18:15 PM by CYNTHIA HEWATT. Confirmation #11603835 Page 1 of 1 Your Elections Benefit Option - Tier Effective Date Employee Paid Pre-tax Benefits Health Benefits BCBS Bronze - You and Family 01/01/2014 Tobacco Surcharge None 01/01/2013 Total Pre-tax cost: Total Monthly cost: Your dependents on file

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Page 1: Enrollment confirm

Confirmation Statement for CYNTHIA HEWATT

Submitted on 11/11/2014 08:18:15 PM by CYNTHIA HEWATT. Confirmation #11603835 Page 1 of 1

Your Elections

Benefit Option - Tier Effective Date MonthlyPremium

Employee Paid Pre-tax Benefits Pre-tax

Health Benefits BCBS Bronze - You and Family 01/01/2014 $260.40

Tobacco Surcharge None 01/01/2013 $0.00

Total Pre-tax cost: $260.40

Total Monthly cost: $260.40

Your dependents on file

Dependent CoverageName Relationship Date of Birth Health Benefit CoverageFORREST G HEWATT Spouse XXXXXX1962

KIRSTEN B HEWATT Child XXXXXX1988

KELTON HEWATT Child XXXXXX1994

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