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New Employee Benefits Enrollment - Dow Corning

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BENEFIT ENROLLMENT WORKSHEET<br />

After reviewing all the benefit selections use this worksheet to record your FLEX benefit selections to<br />

reference while enrolling via ESS.<br />

Dental<br />

Medical<br />

Vision<br />

BENEFIT PLAN OPTION COVERAGE<br />

LEVEL<br />

Dep Life - child $<br />

Dep Life - SP/DP $<br />

Legal<br />

Long Term Disability<br />

Optional Life<br />

AD&D - employee $<br />

AD&D - Spouse/DP $<br />

HSA $<br />

Dep Daycare FSA $<br />

Healthcare FSA $<br />

28

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