AAA Employee Benefit Elections Name* First Last AAA Email Address* Date* Date Format: MM slash DD slash YYYY Medical InsuranceThe options for medical insurance have changed this year. Please make at least one selection below (even if that selection is to waive coverage).Medical Insurance Policy Selection - pick one*CO-IK / RX L27YCO-I2 / RX L27YCO-II / RX L27YWaive all medical coverage optionsThe options for medical insurance have changed this year. Unless you waive coverage you will have to select a plan.Medical Insurance Coverage Level - pick one*Employee Only MedicalEmployee + Spouse MedicalEmployee + Child MedicalEmployee + Family MedicalDental Insurance SectionThere are no changes to the dental plan coverage levels or premium rates for this plan year. Please make at least one selection below (even if that selection is to waive coverage).Dental Insurance Coverage Selection - pick one*United Health Care DPPOWaive Dental CoverageDental Insurance Coverage Level - pick one*Employee Only DentalEmployee + Spouse DentalEmployee + Child DentalEmployee + Family DentalVision Insurance SectionThis is a voluntary group insurance plan. Voluntary means that the employee pays the entire premium. There are no changes to the vision options or rates this year. Please make at least one selection below (even if that selection is to waive coverage).Vision Insurance Coverage Selection - pick one*United Health Care VisionWaive Vision CoverageVision Insurance Coverage Level - pick one*Employee Only VisionEmployee + Spouse VisionEmployee + Child VisionEmployee + Family VisionSupplemental Insurance SectionThis is a voluntary group insurance plan. Voluntary means that the employee pays the entire premium. There have been no changes to the supplemental insurance options or rates. Please make at least one selection below (even if that selection is to waive coverage).Supplemental Insurance Plan Options - choose as many or few as you wish* Transconnect "Gap" Plan Critical Illness Plan Accident Plan Waive All Three Supplemental Coverages Transconnect "Gap" Plan Coverage Level - pick one*Employee Only GapEmployee + Spouse GapEmployee + Child GapEmployee + Family GapCritical Illness Plan Coverage Level - pick one*IndividualOne Parent FamilyTwo Parent FamilyCritical Illness Plan Coverage Amount*Please enter a number from 5000 to 20000.You can purchase insurance in $5,000 increments up to $20,000 for you and each eligible family member. Accident Plan Coverage Level - pick one*Employee Only AccidentEmployee + Spouse AccidentEmployee + Child AccidentEmployee + Family AccidentRetirement Plan SectionAAA contributes a matching contribution to each eligible employee’s Simple IRA equal to the employee’s salary reduction contributions up to 3% of the employee’s compensation for the calendar year. Please make at least one selection below (even if that selection is to waive participation).Retirement Plan Contribution Level - Pick one*One percent (1%)Two percent (2%)Three Percent (3%)None - I do not wish to participate in the retirement planReminder before you submit your selections:Employer Contributions: AAA contributes up to $500 per pay period (including employer taxes) towards certain benefits for eligible employees. In order of priority, AAA contributes 1) a matching contribution to each eligible employee’s Simple IRA equal to the employee’s salary reduction contributions up to 3% of the employee’s compensation for the calendar year, then 2) up to 50% of the employee’s monthly dental insurance premium, then 3) the balance (or up to $500 per pay period if not used for #1 or 2 above) may be used for an eligible employee’s monthly medical insurance premium. If the medical insurance premium is greater than the balance, the employee is responsible for the difference. If the medical insurance premium is less than the balance, the balance may be paid to the employee as a taxable “medical insurance differential” or “MID”. Please email Kim if you have any questions or if you need additional information in order to make your decisions. Δ