Vongkhamphra, Somsalao

Date Printed: 10/29/2015

Employee Benefit Summary Report

Somsalao Vongkhamphra
2618 Riverstone Dr
Murfreesboro, TN, USA 37128-5342
Home Phone:

GENCO
Employer Assigned ID
Date of Hire:
Gender:
Marital Status:

6159047889

113278
07/26/1999
Male
Married

Bi-Weekly Employee Costs: $71.12

Open Enrollment Elections

Full Name
Relationship
Somsalao Vongkhamphra
Subscriber
GENCO Highmark CDHP Choice 2016
Employee and Spouse

Gender
Date of Birth
Male
04/03/1951
Effective: 01/01/2016
Bi-Weekly Cost $23.08

Highmark - Health Reimbursement Account (HRA)

Effective: 01/01/2016

I currently do not use nicotine/tobacco products, and I have not

done so within the past six months.
Tobacco Surcharge

Effective: 01/01/2016

Identity Theft 2016

Aetna PPO 2016
Employee and Spouse

Declined Coverage
Effective: 01/01/2016
Bi-Weekly Cost $10.15

Vision Plan (VBA) 2016

Employee + 1

Effective: 01/01/2016
Bi-Weekly Cost $1.92

CVS Caremark Rx 2016

Employee and Spouse

Effective: 01/01/2016

Health Flexible Spending Account 2016

Dependent Care FSA 2016
Transit Flexible Spending 2016
Basic Life Class 1 2016
1.0 times Salary

Declined Coverage
Declined Coverage
Declined Coverage
Effective: 01/01/2014
Bi-Weekly Cost $0.00

Basic AD&D Class 1 2016

1.0 times Salary

Effective: 01/01/2014
Bi-Weekly Cost $0.00

2016 Optional Life

3 times Salary / 3.0 times Salary

Effective: 01/01/2014
Bi-Weekly Cost $31.98

Optional AD&D - Family 2016

1.0 times Salary

Effective: 01/01/2014
Bi-Weekly Cost $0.76

Optional Dependent Spouse Life 2016

$10,000.00

Effective: 01/01/2014
Bi-Weekly Cost $3.23

Optional Dependent Child Life 2016

Long Term Disability (Non-Exempt) 2016
Pre-Paid Legal 2016
Parking Flexible Spending 2016

Declined Coverage
Effective: 01/01/2014 - 12/31/2014
Declined Coverage
Declined Coverage

Outhayvanh Vongkhamphra
Spouse
GENCO Highmark CDHP Choice 2016
Aetna PPO 2016
Vision Plan (VBA) 2016
CVS Caremark Rx 2016
Optional Dependent Spouse Life 2016

Bi-Weekly Cost $0.00

Female
01/10/1954
Effective: 01/01/2016
Effective: 01/01/2016
Effective: 01/01/2016
Effective: 01/01/2016

Bi-Weekly Employee Costs: $125.99

Current Elections
Full Name
Somsalao Vongkhamphra

Relationship
Subscriber

Gender
Male

Date of Birth
04/03/1951

Legacy GENCO Highmark PPO 2015

Employee and Spouse

Effective: 01/01/2015
Bi-Weekly Cost $76.62

I currently do not use nicotine/tobacco products, and I have not

done so within the past six months.
Tobacco Surcharge

Effective: 01/01/2015

Identity Theft 2015

Aetna PPO 2015
Employee and Spouse

Declined Coverage
Effective: 01/01/2015
Bi-Weekly Cost $9.57

Vision Plan (VBA) 2015

Employee + 1

Effective: 01/01/2015
Bi-Weekly Cost $3.83

CVS Caremark Rx 2015

Employee and Spouse

Effective: 01/01/2015

Health Flexible Spending Account 2015

Dependent Care FSA 2015
Transit Flexible Spending 2015
Basic Life Class 1 2015
1.0 times Salary

Declined Coverage
Declined Coverage
Declined Coverage
Effective: 01/01/2014
Bi-Weekly Cost $0.00

Basic AD&D Class 1 2015

1.0 times Salary

Effective: 01/01/2014
Bi-Weekly Cost $0.00

2015 Optional Life

3 times Salary / 3.0 times Salary

Effective: 01/01/2014
Bi-Weekly Cost $31.98

Optional AD&D - Family 2015

1.0 times Salary

Effective: 01/01/2014
Bi-Weekly Cost $0.76

Optional Dependent Spouse Life 2015

$10,000.00

Effective: 01/01/2014
Bi-Weekly Cost $3.23

Optional Dependent Child Life 2015

Long Term Disability (Non-Exempt) 2015
Pre-Paid Legal 2015
Parking Flexible Spending 2015

Declined Coverage
Effective: 01/01/2014 - 12/31/2014
Declined Coverage
Declined Coverage

Bi-Weekly Cost $0.00

Outhayvanh Vongkhamphra
Spouse
Legacy GENCO Highmark PPO 2015
Aetna PPO 2015
Vision Plan (VBA) 2015
CVS Caremark Rx 2015
Optional Dependent Spouse Life 2015

Female
01/10/1954
Effective: 01/01/2015
Effective: 01/01/2015
Effective: 01/01/2015
Effective: 01/01/2015

Sarah Vongkhamphra
Child
Legacy GENCO Highmark PPO 2015

Female
12/20/1990
Declined Coverage

Humana Voluntary Benefits

Humana Disability Income Advantage
DIA Non Occ
Plan: IA
Policy Number: 2693630
Premium Deduction: PostTax
Waived
Persons Covered

Per Pay Period

Per Year

Your Costs
$38.98
$1,013.48

Employer Costs

Name
SOMSALAO
VONGKAMPHRA

Relationship
SUBSCRIBER

Key
Person is covered by the benefit
The benefit coverage will be ending
Person is no longer covered by the benefit

Effective Date
01/01/2012

End Date