| |
Last
Year’s Expenses
|
This
Year’s Projected Expenses
|
| Insurance
deductibles |
|
|
Medical/dental/prescription
co-payments
|
|
|
| Documented
over-the-counter medicines |
|
|
| Dental
expenses |
|
|
| Eye
glasses and contacts |
|
|
| Routine
examinations & physicals |
|
|
| Transportation
to/from medical provider |
|
|
| Non-cosmetic
surgery |
|
|
| Medically
necessary nursing home care |
|
|
| Total
expenses for the year |
|
|
| Divide
total by your number of regular pay periods |
| Enter
this amount into your Election Form. |
