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(RFP) - Terminal Operator Services for the Statewide Fingerprint ...

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<strong>RFP</strong> Appendix D, Exhibit 14<br />

Medical Insurance/Health Plan:<br />

EMPLOYEE BENEFITS<br />

For<br />

SFIS TERMINAL OPERATORS<br />

Employer Pays $________Employee Pays $________Total Mo. Premium $________<br />

Annual Deductible<br />

Employee $_______ Family $_______<br />

Coverage (√)<br />

______ Hospital Care (In Patient _____ Out Patient ______)<br />

______ X-Ray and Laboratory<br />

______ Surgery<br />

______ Office Visits<br />

______ Pharmacy<br />

______ Maternity<br />

______ Mental Health/Chemical Dependency, In Patient<br />

______ Mental Health/Chemical Dependency, Out Patient<br />

Dental Insurance:<br />

Employer Pays $________Employee Pays $________Total Mo. Premium $________<br />

Life Insurance:<br />

Employer Pays $________Employee Pays $________Total Mo. Premium $________<br />

Paid Holidays:<br />

Number of Days _______ per year<br />

187

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