companyname
returnaddress
DO NOT MAIL CORRESPONDENCE OR PAYMENTS TO THIS ADDRESS	logo	

	member.1.fname member.1.lname member.1.suffix
member.1.personal.address1
member.1.personal.address2
member.1.personal.city xmember.1.personal.state xmember.1.personal.zip 	
Notice Date:  currentdate

Member Name: member.1.fname member.1.lname member.1.suffix

Your Benefits Enrollment Confirmation Statement	
If you have any questions regarding your benefits or this notice, please log in to company.1.websiteurl.

companyname’s Benefits Enrollment has ended, and your benefits have been set for the upcoming plan year.  Attached is a summary of your benefits and costs effective member.ae.effectivedate.

Log in to company.1.websiteurl today to review additional details and other important information regarding your benefits.

In addition to reviewing your benefits for the upcoming plan year, company.1.websiteurl is your one-stop-shop for your benefits through companyname.

•	Update your contact preferences to ensure you are receiving important information regarding your benefits.
•	Upload required documentation for your covered dependents.
•	Chat with a member of our team at any time – day or night.

Are my newly-added dependent(s) approved?
If you elected to add any new dependents to your benefits during enrollment, you are required to provide documentation that verifies their eligibility.  Until the requested documentation is submitted, your changes will not be approved. Once all required documentation is received, action will be taken to update your elections and send the requested changes to your insurance providers. Documentation can be securely uploaded online at company.1.websiteurl.  Log in to company.1.websiteurl to review documentation requirements and submit the required information.

What if I want to change my benefits later?
Once Benefits Enrollment closes, your benefits are set for the year. You cannot change or add coverage unless you have a qualifying life event or status change.

If you have any questions regarding your benefits or this notice, please log in to company.1.websiteurl.

Thank you,
companyname

Your Benefits Enrollment Confirmation Statement
Your approved benefits for next year, as of currentdate

A summary of information already available on your account is provided below, including a snapshot of your approved elections and costs for the upcoming plan year.  Please review for accuracy and log in to company.1.websiteurl for additional details as well as review a summary of your current benefit elections.

Log in to company.1.websiteurl to review additional details regarding your benefits, including covered dependents, contribution details for spending accounts, or your current year elections and costs.

Once Benefits Enrollment closes, your benefit coverages are set for the year!  You cannot change or add coverage unless you have a qualifying life event or status change.

YOUR INFORMATION	

Name
member.1.fname member.1.lname member.1.suffix 

Address
member.1.personal.address1
member.1.personal.address2
member.1.personal.city xmember.1.personal.state xmember.1.personal.zip 
	
Gender
member.1.personal.gender

Date of Birth
member.1.personal.dob	

DEPENDENT INFORMATION	
First Name	Last Name	Relationship	Gender	Date of Birth	
					
member.2.fname 	member.2.lname	member.2.relation	member.2.personal.gender	member.2.personal.dob	
member.3.fname 	member.3.lname	member.3.relation	member.3.personal.gender	member.3.personal.dob	
member.4.fname 	member.4.lname	member.4.relation	member.4.personal.gender	member.4.personal.dob	
member.5.fname 	member.5.lname	member.5.relation	member.5.personal.gender	member.5.personal.dob	
member.6.fname 	member.6.lname	member.6.relation	member.6.personal.gender	member.6.personal.dob	
member.7.fname 	member.7.lname	member.7.relation	member.7.personal.gender	member.7.personal.dob	
member.8.fname 	member.8.lname	member.8.relation	member.8.personal.gender	member.8.personal.dob	
member.9.fname 	member.9.lname	member.9.relation	member.9.personal.gender	member.9.personal.dob	
member.10.fname 	member.10.lname	member.10.relation	member.10.personal.gender	member.10.personal.dob	
member.11.fname 	member.11.lname	member.11.relation	member.11.personal.gender	member.11.personal.dob	

ELECTION INFORMATION	
member.1.planelection.credit.pu_id_name
member.1.planelection.credit.plan	blank_field	member.1.planelection.credit.price	
			
My Health

Plan	Coverage	Employee Cost	
			
member.1.planelection.medical.pu_id_name
member.1.planelection.medical.plan	member.1.planelection.medical.tier member.1.planelection.medical.eoi	member.1.planelection.medical.surchargeprice
member.1.planelection.medical.price2	
member.1.planelection.medical2.pu_id_name
member.1.planelection.medical2.plan	member.1.planelection.medical2.tier member.1.planelection.medical2.eoi	member.1.planelection.medical2.surchargeprice	
member.1.planelection.mod.pu_id_name
member.1.planelection.mod.plan	member.1.planelection.mod.tier member.1.planelection.mod.eoi	member.1.planelection.mod.price	
member.1.planelection.pdg.pu_id_name
member.1.planelection.pdg.plan	member.1.planelection.pdg.tier member.1.planelection.pdg.eoi	member.1.planelection.pdg.price	
member.1.planelection.dental.pu_id_name
member.1.planelection.dental.plan	member.1.planelection.dental.tier member.1.planelection.dental.eoi	member.1.planelection.dental.price	
member.1.planelection.vision.pu_id_name
member.1.planelection.vision.plan	member.1.planelection.vision.tier member.1.planelection.vision.eoi	member.1.planelection.vision.price	
member.1.planelection.volci.pu_id_name
member.1.planelection.volci.plan	member.1.planelection.volci.tier	member.1.planelection.volci.price	
member.1.planelection.volci2.pu_id_name
member.1.planelection.volci2.plan	member.1.planelection.volci2.tier	member.1.planelection.volci2.price	
member.1.planelection.voleeci.pu_id_name
member.1.planelection.voleeci.plan	blank_field	member.1.planelection.voleeci.price	
member.1.planelection.voleeci2.pu_id_name
member.1.planelection.voleeci2.plan	blank_field	member.1.planelection.voleeci2.price	
member.1.planelection.volspci.pu_id_name
member.1.planelection.volspci.plan	blank_field	member.1.planelection.volspci.price	
member.1.planelection.volspci2.pu_id_name
member.1.planelection.volspci2.plan	blank_field	member.1.planelection.volspci2.price	
member.1.planelection.volchci.pu_id_name
member.1.planelection.volchci.plan	blank_field	member.1.planelection.volchci.price	
member.1.planelection.volchci2.pu_id_name
member.1.planelection.volchci2.plan	blank_field	member.1.planelection.volchci2.price	
member.1.planelection.volacc.pu_id_name
member.1.planelection.volacc.plan	member.1.planelection.volacc.tier	member.1.planelection.volacc.price	
member.1.planelection.volaccident.pu_id_name
member.1.planelection.volaccident.plan	member.1.planelection.volaccident.tier	member.1.planelection.volaccident.price	
member.1.planelection.volhosp.pu_id_name
member.1.planelection.volhosp.plan	blank_field	member.1.planelection.volhosp.price	

			
My Savings

Plan	Annual Contribution	Employee Contributions	
			
member.1.planelection.hsa.pu_id_name
member.1.planelection.hsa.plan	member.1.planelection.hsa.cov_amt	member.1.planelection.hsa.hsaamount	
member.1.planelection.flex.pu_id_name
member.1.planelection.flex.plan	member.1.planelection.flex.cov_amt	member.1.planelection.flex.medamount	
member.1.planelection.flex2.pu_id_name
member.1.planelection.flex2.plan	member.1.planelection.flex2.cov_amt	member.1.planelection.flex2.depamount	
member.1.planelection.gsa.pu_id_name
member.1.planelection.gsa.plan	member.1.planelection.gsa.cov_amt 	member.1.planelection.gsa.price	
member.1.planelection.401k.pu_id_name
member.1.planelection.401k.plan	blank_field	member.1.planelection.401k.price	

			
My Security

Plan	Coverage	Employee Cost	
			
member.1.planelection.life.pu_id_name
member.1.planelection.life.plan	member.1.planelection.life.cov_amt member.1.planelection.life.eoi	member.1.planelection.life.price	
member.1.planelection.life2.pu_id_name
member.1.planelection.life2.plan	member.1.planelection.life2.cov_amt member.1.planelection.life2.eoi	member.1.planelection.life2.price	
member.1.planelection.life3.pu_id_name
member.1.planelection.life3.plan	member.1.planelection.life3.cov_amt member.1.planelection.life3.eoi	member.1.planelection.life3.price	
member.1.planelection.life4.pu_id_name
member.1.planelection.life4.plan	member.1.planelection.life4.cov_amt member.1.planelection.life4.eoi	member.1.planelection.life4.price	
member.1.planelection.life5.pu_id_name
member.1.planelection.life5.plan	member.1.planelection.life5.cov_amt member.1.planelection.life5.eoi	member.1.planelection.life5.price	
member.1.planelection.life6.pu_id_name
member.1.planelection.life6.plan	member.1.planelection.life6.cov_amt member.1.planelection.life6.eoi	member.1.planelection.life6.price	
member.1.planelection.life7.pu_id_name
member.1.planelection.life7.plan	member.1.planelection.life7.cov_amt member.1.planelection.life7.eoi	member.1.planelection.life7.price	
member.1.planelection.life8.pu_id_name
member.1.planelection.life8.plan	member.1.planelection.life8.cov_amt member.1.planelection.life8.eoi	member.1.planelection.life8.price	
member.1.planelection.vollife.pu_id_name
member.1.planelection.vollife.plan	member.1.planelection.vollife.cov_amt member.1.planelection.vollife.eoi	member.1.planelection.vollife.price	
member.1.planelection.vollife2.pu_id_name
member.1.planelection.vollife2.plan	member.1.planelection.vollife2.cov_amt member.1.planelection.vollife2.eoi	member.1.planelection.vollife2.price	
member.1.planelection.voladd.pu_id_name
member.1.planelection.voladd.plan	member.1.planelection.voladd.cov_amt member.1.planelection.voladd.eoi	member.1.planelection.voladd.price	
member.1.planelection.volsplife.pu_id_name
member.1.planelection.volsplife.plan	member.1.planelection.volsplife.cov_amt member.1.planelection.volsplife.eoi	member.1.planelection.volsplife.price	
member.1.planelection.volsplife2.pu_id_name
member.1.planelection.volsplife2.plan	member.1.planelection.volsplife2.cov_amt member.1.planelection.volsplife2.eoi	member.1.planelection.volsplife2.price	
member.1.planelection.volspadd.pu_id_name
member.1.planelection.volspadd.plan	member.1.planelection.volspadd.cov_amt member.1.planelection.volspadd.eoi	member.1.planelection.volspadd.price	
member.1.planelection.volspadd2.pu_id_name
member.1.planelection.volspadd2.plan	member.1.planelection.volspadd2.cov_amt member.1.planelection.volspadd2.eoi	member.1.planelection.volspadd2.price	
member.1.planelection.volchlife.pu_id_name
member.1.planelection.volchlife.plan	member.1.planelection.volchlife.cov_amt member.1.planelection.volchlife.eoi	member.1.planelection.volchlife.price	
member.1.planelection.volchlife2.pu_id_name
member.1.planelection.volchlife2.plan	member.1.planelection.volchlife2.cov_amt member.1.planelection.volchlife2.eoi	member.1.planelection.volchlife2.price	
member.1.planelection.volchadd.pu_id_name
member.1.planelection.volchadd.plan	member.1.planelection.volchadd.cov_amt member.1.planelection.volchadd.eoi	member.1.planelection.volchadd.price	
member.1.planelection.volchadd2.pu_id_name
member.1.planelection.volchadd2.plan	member.1.planelection.volchadd2.cov_amt member.1.planelection.volchadd2.eoi	member.1.planelection.volchadd2.price	
member.1.planelection.deplife.pu_id_name
member.1.planelection.deplife.plan	member.1.planelection.deplife.cov_amt  member.1.planelection.deplife.eoi	member.1.planelection.deplife.price	
member.1.planelection.deplife2.pu_id_name
member.1.planelection.deplife2.plan	member.1.planelection.deplife2.cov_amt member.1.planelection.deplife2.eoi	member.1.planelection.deplife2.price	
member.1.planelection.std.pu_id_name
member.1.planelection.std.plan	blank_field	member.1.planelection.std.price	
member.1.planelection.std2.pu_id_name
member.1.planelection.std2.plan	blank_field	member.1.planelection.std2.price	
member.1.planelection.ltd.pu_id_name
member.1.planelection.ltd.plan	blank_field	member.1.planelection.ltd.price	
member.1.planelection.ltd2.pu_id_name
member.1.planelection.ltd2.plan	blank_field	member.1.planelection.ltd2.price	
member.1.planelection.ltd3.pu_id_name
member.1.planelection.ltd3.plan	blank_field	member.1.planelection.ltd3.price	
member.1.planelection.db.pu_id_name
member.1.planelection.db.plan	blank_field	member.1.planelection.db.price	
member.1.planelection.dbl.pu_id_name
member.1.planelection.dbl.plan	blank_field	member.1.planelection.dbl.price	
member.1.planelection.cancer1.pu_id_name
member.1.planelection.cancer1.plan	member.1.planelection.cancer1.tier	member.1.planelection.cancer1.price	
member.1.planelection.cancer2.pu_id_name
member.1.planelection.cancer2.plan	member.1.planelection.cancer2.tier	member.1.planelection.cancer2.price	
member.1.planelection.cancer3.pu_id_name
member.1.planelection.cancer3.plan	member.1.planelection.cancer3.tier	member.1.planelection.cancer3.price	
member.1.planelection.cancer4.pu_id_name
member.1.planelection.cancer4.plan	member.1.planelection.cancer4.tier	member.1.planelection.cancer4.price	
member.1.planelection.cancer5.pu_id_name
member.1.planelection.cancer5.plan	member.1.planelection.cancer5.tier	member.1.planelection.cancer5.price	
member.1.planelection.cancer6.pu_id_name
member.1.planelection.cancer6.plan	member.1.planelection.cancer6.tier	member.1.planelection.cancer6.price	
member.1.planelection.cancer7.pu_id_name
member.1.planelection.cancer7.plan	member.1.planelection.cancer7.tier	member.1.planelection.cancer7.price	
member.1.planelection.cancer8.pu_id_name
member.1.planelection.cancer8.plan	member.1.planelection.cancer8.tier	member.1.planelection.cancer8.price	
member.1.planelection.legal.pu_id_name
member.1.planelection.legal.plan	blank_field	member.1.planelection.legal.price	
member.1.planelection.legal2.pu_id_name
member.1.planelection.legal2.plan	blank_field	member.1.planelection.legal2.price	
member.1.planelection.legal3.pu_id_name
member.1.planelection.legal3.plan	blank_field	member.1.planelection.legal3.price	
member.1.planelection.legal4.pu_id_name
member.1.planelection.legal4.plan	blank_field	member.1.planelection.legal4.price	
member.1.planelection.legal5.pu_id_name
member.1.planelection.legal5.plan	blank_field	member.1.planelection.legal5.price	
member.1.planelection.legal6.pu_id_name
member.1.planelection.legal6.plan	blank_field	member.1.planelection.legal6.price	
member.1.planelection.legal7.pu_id_name
member.1.planelection.legal7.plan	blank_field	member.1.planelection.legal7.price	
member.1.planelection.legal8.pu_id_name
member.1.planelection.legal8.plan	blank_field	member.1.planelection.legal8.price	
member.1.planelection.ltc.pu_id_name
member.1.planelection.ltc.plan	blank_field	member.1.planelection.ltc.price	

			
Other

Plan	Coverage	Employee Cost
member.1.employment.payfrequency	
			
member.1.planelection.transit.pu_id_name
member.1.planelection.transit.plan	blank_field	member.1.planelection.transit.price	
member.1.planelection.parking.pu_id_name
member.1.planelection.parking.plan	blank_field	member.1.planelection.parking.price	
member.1.planelection.voluntary1.pu_id_name
member.1.planelection.voluntary1.plan	blank_field	member.1.planelection.voluntary1.price	
member.1.planelection.voluntary2.pu_id_name
member.1.planelection.voluntary2.plan	blank_field	member.1.planelection.voluntary2.price	
member.1.planelection.voluntary3.pu_id_name
member.1.planelection.voluntary3.plan	blank_field	member.1.planelection.voluntary3.price	
member.1.planelection.voluntary4.pu_id_name
member.1.planelection.voluntary4.plan	blank_field	member.1.planelection.voluntary4.price	
member.1.planelection.voluntary5.pu_id_name
member.1.planelection.voluntary5.plan	blank_field	member.1.planelection.voluntary5.price	
member.1.planelection.voluntary6.pu_id_name
member.1.planelection.voluntary6.plan	blank_field	member.1.planelection.voluntary6.price	
member.1.planelection.voluntary7.pu_id_name
member.1.planelection.voluntary7.plan	blank_field	member.1.planelection.voluntary7.price	
member.1.planelection.voluntary8.pu_id_name
member.1.planelection.voluntary8.plan	blank_field	member.1.planelection.voluntary8.price	
member.1.planelection.voluntary9.pu_id_name
member.1.planelection.voluntary9.plan	blank_field	member.1.planelection.voluntary9.price	
member.1.planelection.stock.pu_id_name
member.1.planelection.stock.plan	blank_field	member.1.planelection.stock.price	

Any information with an asterisk (*) indicates a change that is currently pending approval.  Employee Costs displayed on this benefit summary reflect your currently approved coverage level, and any pending elections may result in a change to this amount, if approved.  Log in to company.1.websiteurl to review additional information pertaining to your benefits.	

BENEFICIARY INFORMATION	
member.1.planelection.life.pu_id_name
member.1.planelection.life.beneficiary	
member.1.planelection.life2.pu_id_name
member.1.planelection.life2.beneficiary	
member.1.planelection.life3.pu_id_name
member.1.planelection.life3.beneficiary	
member.1.planelection.life4.pu_id_name
member.1.planelection.life4.beneficiary	
member.1.planelection.life5.pu_id_name
member.1.planelection.life5.beneficiary	
member.1.planelection.life6.pu_id_name
member.1.planelection.life6.beneficiary	
member.1.planelection.life7.pu_id_name
member.1.planelection.life7.beneficiary	
member.1.planelection.life8.pu_id_name
member.1.planelection.life8.beneficiary	
member.1.planelection.vollife.pu_id_name
member.1.planelection.vollife.beneficiary	
member.1.planelection.vollife2.pu_id_name
member.1.planelection.vollife2.beneficiary	
member.1.planelection.voladd.pu_id_name
member.1.planelection.voladd.beneficiary