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

Hello member.1.fname member.1.lname,

Attached is a summary of your approved benefit elections and costs, as well as any dependent and beneficiary information we have on file.  You may also log in to company.1.websiteurl today to review your current elections and other important information regarding your benefits.

Your Benefits Information – Available 24/7

Go to company.1.cobraurl and log in with your username and password. If you don’t know them, you may reset your username and password or Register as a first-time user. Your Company Key is company.1.companykey.

In addition to reviewing and updating your elections, company.1.cobraurl 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.	
	Download the 
MyChoice® benefits app

All your benefits in the 
palm of your hand.

Once your download it, log in to company.1.websiteurl to receive your access code.	

Are my newly-added dependent(s) covered? 
If you elected to add any new dependent(s) to your coverages for this plan year, you may be required to provide documentation that verifies their eligibility.  Log in to company.1.websiteurl to review your dependent(s)’ verification status and upload the required documentation.

What if I want to change my coverage later?
Once your enrollment period 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.

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

Thank you,

companyname x company.1.signature 

Your Benefit Summary
Your approved benefits as of currentdate

A summary of information 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 your enrollment period 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.

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

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	Verified Date	
						
member.2.fname 	member.2.lname	member.2.relation	member.2.personal.gender	member.2.personal.dob	member.2.personal.verifieddate	
member.3.fname 	member.3.lname	member.3.relation	member.3.personal.gender	member.3.personal.dob	member.3.personal.verifieddate	
member.4.fname 	member.4.lname	member.4.relation	member.4.personal.gender	member.4.personal.dob	member.4.personal.verifieddate	
member.5.fname 	member.5.lname	member.5.relation	member.5.personal.gender	member.5.personal.dob	member.5.personal.verifieddate	
member.6.fname 	member.6.lname	member.6.relation	member.6.personal.gender	member.6.personal.dob	member.6.personal.verifieddate	
member.7.fname 	member.7.lname	member.7.relation	member.7.personal.gender	member.7.personal.dob	member.7.personal.verifieddate	
member.8.fname 	member.8.lname	member.8.relation	member.8.personal.gender	member.8.personal.dob	member.8.personal.verifieddate	
member.9.fname 	member.9.lname	member.9.relation	member.9.personal.gender	member.9.personal.dob	member.9.personal.verifieddate	
member.10.fname 	member.10.lname	member.10.relation	member.10.personal.gender	member.10.personal.dob	member.10.personal.verifieddate	
member.11.fname 	member.11.lname	member.11.relation	member.11.personal.gender	member.11.personal.dob	member.11.personal.verifieddate	

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	
member.1.planelection.volacc.pu_id_name
member.1.planelection.volacc.beneficiary	
member.1.planelection.cancer1.pu_id_name
member.1.planelection.cancer1.beneficiary	
member.1.planelection.cancer2.pu_id_name
member.1.planelection.cancer2.beneficiary