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Employee Contributions for 2011 <br />Health Care Contributions <br />The Southern Ute Indian Tribe pays a large portion of Health Care Plan coverage for employees. <br />• If an Employee elects Employee Only coverage for Medical, Dental or Vision the employee pays 5% of the total <br />cost of coverage and the Tribe pays 95% of the cost of the coverage. <br />• If an Employee elects Dependent coverage for Medical, Dental or Vision the employee pays 25% of the total cost <br />of coverage and the Tribe pays 75% of the cost of the coverage. <br />• The Employer cost per month for 2011 is shown in the shaded column. <br />Basic Life Insurance <br />The Tribe provides employees Basic Life Insurance and AD &D equal two (2) times Annual Earnings, rounded to the next <br />higher $1,000, if not already an even multiple thereof. The maximum benefit is $500,000; minimum benefit is $10,000 <br />Coverage. The cost of the coverage is $.225 per $1,000 of coverage. The Tribal also provides Dependent Life insurance and <br />the cost is 1.46 per person per month <br />Long Term Disability <br />The Tribe provides employees Long Term Disability equal 60% of pre disability earnings with a maximum monthly benefit of <br />$10,000. <br />Amount <br />Amount <br />Coverage <br />Total <br />Amount <br />Your <br />Level <br />Plan <br />Monthly <br />Employer <br />Pay <br />Pay <br />Per <br />Cost <br />Pays <br />t ly <br />Mon h <br />Monthly <br />Paycheck <br />Medical <br />$ <br />522.95 <br />$ <br />496.81 <br />$ <br />26.14 <br />$ <br />13.07 <br />Employee <br />Dental <br />$ <br />33.65 <br />$ <br />31.95 <br />$ <br />1.70 <br />$ <br />0.85 <br />Only <br />Vision <br />$ <br />8.98 <br />$ 8.52 <br />$ 0.46 <br />$ <br />0.23 <br />$ <br />565.58 <br />$ <br />28.30 <br />$ <br />14.15 <br />Medical, Dental & Vision <br />$ 537.28 <br />Medical <br />$ <br />1,045.95 <br />$ <br />784.45 <br />$ <br />261.50 <br />$ <br />130.75 <br />Employee <br />Dental <br />$ <br />62.99 <br />$ <br />47.21 <br />$ <br />15.78 <br />$ <br />7.89 <br />& <br />Vision <br />$ <br />14.50 <br />$ <br />10.88 <br />$ <br />3.62 <br />$ <br />1.81 <br />Spouse <br />Medical, Dental& Vision <br />$ <br />1,123.44 <br />$ <br />842.54 <br />$ <br />280.90 <br />$ <br />140.45 <br />Medical <br />$ <br />993.68 <br />$ <br />745.26 <br />$ <br />248.42 <br />$ <br />124.21 <br />Employee <br />Dental <br />$ <br />79.07 <br />$ <br />59.29 <br />$ <br />19.78 <br />$ <br />9.89 <br />& <br />Vision <br />$ <br />14.78 <br />$ <br />11.08 <br />$ <br />3.70 <br />$ <br />1.85 <br />Child(ren) <br />Medical, Dental & Vision <br />$ <br />1,087.53 <br />$ <br />815.63 <br />$ <br />271.90 <br />$ <br />135.95 <br />Medical <br />$ <br />1,516.60 <br />$ <br />1,137.44 <br />$ <br />379.16 <br />$ <br />189.58 <br />Dental <br />$ <br />108.41 <br />$ <br />81.29 <br />$ <br />27.12 <br />$ <br />13.56 <br />Family <br />Vision <br />$ <br />23.62 <br />$ <br />17.70 <br />$ <br />5.92 <br />$ <br />2.96 <br />$ <br />1,648.63 <br />$ <br />1,236.43 <br />$ <br />412.20 <br />$ <br />206.10 <br />Medical, Dental & Vision <br />Basic Life Insurance <br />The Tribe provides employees Basic Life Insurance and AD &D equal two (2) times Annual Earnings, rounded to the next <br />higher $1,000, if not already an even multiple thereof. The maximum benefit is $500,000; minimum benefit is $10,000 <br />Coverage. The cost of the coverage is $.225 per $1,000 of coverage. The Tribal also provides Dependent Life insurance and <br />the cost is 1.46 per person per month <br />Long Term Disability <br />The Tribe provides employees Long Term Disability equal 60% of pre disability earnings with a maximum monthly benefit of <br />$10,000. <br />