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Election Summary PDF

This document summarizes MD Noore A Sarkar's benefits elections for 2018. It provides his personal and employment information, including dependents. Mr. Sarkar elected the PPO medical plan, dental plan, and vision plan for himself. He waived the HSA, FSA, voluntary life and AD&D plans. His employer provides basic life/AD&D, short term disability, and long term disability coverage at no cost. The total bi-weekly cost for his vision coverage is $3.45 and the annual cost is $89.64.

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Noore Alam Sarkar
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167 views1 page

Election Summary PDF

This document summarizes MD Noore A Sarkar's benefits elections for 2018. It provides his personal and employment information, including dependents. Mr. Sarkar elected the PPO medical plan, dental plan, and vision plan for himself. He waived the HSA, FSA, voluntary life and AD&D plans. His employer provides basic life/AD&D, short term disability, and long term disability coverage at no cost. The total bi-weekly cost for his vision coverage is $3.45 and the annual cost is $89.64.

Uploaded by

Noore Alam Sarkar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Election Summary

RPS Elections effective as of : 01/01/2018

Personal Information Employment Information


Employee: MD Noore A Sarkar Title: Structural Engineer
Address: 12951 Briar Forest Dr#1321 Date of hire: 08/21/2017
Address 2: Annual pay periods: 26
City, State, ZIP: Houston, TX 77077
SSN: 361-35-1169
Date of birth: 12/25/1979
Gender: Male
Dependents / Beneficiaries
SSN/DOB/
Name Address Relationship Dependent Beneficiary
Gender
Amena Akter 12951 Briar Forest Dr#1321 Spouse 394-35-0838 Yes Yes
Houston, TX 77077 02/21/1986
Female
Nusaiba Tiba 12951 Briar Forest Dr#1321 Child 301-89-0216 Yes No
Houston, TX 77077 09/04/2011
Female
Nourin Towa 12951 Briar Forest Dr#1321 Child 122-57-5231 Yes No
Houston, TX 77077 11/08/2013
Female
Elections
Dependent / Effective Per Pay Period Annual
Plan Type Selected Benefit
Beneficiary Date Amount Cost
Medical 2018 PPO Medical Plan 1/1/2018 $0.00 $0.00
Employee Employee Only - Bi-
Weekly

HSA Waived 1/1/2018 $0.00 $0.00


FSA Waived 1/1/2018 $0.00 $0.00
Dental 2018 Dental Plan 1/1/2018 $0.00 $0.00
Employee Employee Only - Bi-
Weekly

Vision 2018 Vision 1/1/2018 $3.45 $89.64


Employee Employee Only - Bi-
Weekly

Employer Paid Life & 2018 Basic Life & AD&D MD Noore Sarkar- (P) Amena Akter - 1/1/2018 $0.00 $0.00
100.00%
AD&D
Voluntary Life & AD&D Waived 1/1/2018 $0.00 $0.00
Employer Paid Short 2018 Short Term Disability 1/1/2018 $0.00 $0.00
Term Disability
Employer Paid Long 2018 Long Term Disability 1/1/2018 $0.00 $0.00
Term Disability
Total Cost of Benefits $3.45 $89.64

To view additional benefits, log in to http://www.hrconnection.com.

Authorization

signature date

Election Summary
Printed on : 2017-12-05 00:00:00

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