Total Pre-Tax Premium $
Company Gross Savings $
Less Admin Fee $
NET Savings Per-Pay-Period $
| Pay Period | Weekly |
| Gross Pay | $00.00 |
| Marital Status | Married Filing Jointly |
| Allowances | 2 |
| Dependents Amount | $0 |
| Additional Withholding | - |
| Pre-tax | - |
| After-Tax | - |
| 401k | $161.54 |
| Major Medical | $115.38 |
| Net Taxable Income | 00.00 |
| Federal Income Tax | $00.00 |
| State Tax | $00.00 |
| Medicare | $00.00 |
| Social Security | $00.00 |
| SDI | - |
| NET PAY | $00.00 |
| Pay Period | |
| Gross Pay | $00.00 |
| Marital Status | Married Filing Jointly |
| Allowances | 2 |
| Dependents Amount | $0 |
| Additional Withholding | - |
| Pre-tax | - |
| Premium | $00.00 |
| After-Tax | - |
| 401k | $161.54 |
| Major Medical | $115.38 |
| Net Taxable Income | $00.00 |
| Federal Income Tax | $00.00 |
| State Tax | $00.00 |
| Medicare | $00.00 |
| Social Security | $00.00 |
| SDI | - |
| Claim Payment | $00.00 |
| Post-tax Premium | - |
| NET PAY | $00.00 |