| $3000/100% HSA Qualified Plan | ||||
| Employee Status | # | Employee Premium | Dependent Premium | Total Premium |
| EE only | 15 | $182.85 | $ - | $2,742.75 |
| EE / Spouse | 5 | $182.85 | $210.30 | $1,965.75 |
| EE/Child | 8 | $182.85 | $164.60 | $2,779.60 |
| Family | 12 | $182.85 | $429.75 | $7,351.20 |
| Total EE | 40 | |||
| Monthly Totals | $7,314.00 | $7,525.30 | $14,839.30 | |
| Annual Totals | $87,768.00 | $90,303.60 | $ 178,071.60 | |
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