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LOMV PLOYER NAME <br />KITT1TA5 COUNTY <br />DENTAL PLANS <br />WCIF dental plans require 100% employee participation. If elected, all eligible employees must be covered. <br />1 DE <br />LTA DENTAL OF WASHINGTON .................... ........ ® CHECK TO DECLINE COVERAGE <br />PLAN A 1 $1,000 Annual Maximum PPO Plan <br />A-1 (100% Employer Paid) <br />❑ 2 -Tiered Rates (EE / 1+ Dependent) <br />❑ Composite Rate <br />PLAN C 1 $1,000 Annual Maximum Enhanced Plan <br />C-1 600% Employer Paid) <br />❑ 2 -Tiered Rates (EE / 1+ Dependent) <br />❑ Composite Rate <br />C-2 (100% Employer Paid Except Dependents) <br />❑ 3 -Tiered Rates <br />(EE / 1 Dependent / 2+ Dependents) <br />INCENTIVE PLAN 1 $2,000 Annual Maximum <br />Incentive -1 (100% Employer Paid) <br />❑ 2 -Tiered Rates (EE / 1+ Dependent) <br />❑ Composite Rate <br />PLAN B 1 $2,000 Annual Maximum PPO Plan <br />B-4 (100% Employer Paid Except Dependent <br />❑ 3 -Tiered Rates <br />(EE / 1 Dependent / 2+ Dependents) <br />i <br />PLAN D 1 $2,000 Annual Maximum Enhanced Plan <br />D-3 (100% Employer Paid) <br />❑ 2 -Tiered Rates (EE / 1+ Dependent) <br />❑ Composite Rate <br />D-4 (100% Employer Paid Except Dependents) <br />❑ 3 -Tiered Rates <br />(EE / 1 Dependent / 2+ Dependents) <br />OTHER PLAN <br />❑ Plan Name: <br />11. WILLAMETTE DENTAL OF WASHINGTON INC .................... . ® CHECK TO DECLINE COVERAGE <br />❑ 3 -Tiered Rates OTHER PLAN <br />❑ Composite Rate ❑ Plan Name.- <br />VISION <br />ame: <br />VISION PLANS <br />WCIF vision plans require 100% employee participation, employer paid. If elected, all eligible employees must be <br />covered. <br />1. VSP Vision Care, Inc ............................................. ® CHECK TO DECLINE COVERAGE <br />EXTENDED PLAN <br />STANDARD PLAN <br />BUDGET PLAN <br />OTHER PLAN <br />❑ 4 -Tiered Rates <br />❑ 4 -Tiered Rates <br />❑ 4 -Tiered Rates <br />❑ Plan Name: <br />❑ Composite Rate <br />❑ Composite Rate <br />❑ Composite Rate <br />2017GMA2 Page 5 of 9 (092116JM) <br />