ENROLLMENT WORKSHEET

Employee Name:

Employee Benefits Worksheet

This enrollment worksheet outlines the options available to you for the 2015 - 2016 plan year and the corresponding costs. Any elections/waivers that you make will remain in force until the next open enrollment period for that benefit. Please follow the guidelines below to complete your enrollment for this years’ programs.

Instructions:

Review the benefit options available to you. Complete enrollment forms attached to this sheet (even if you are waiving coverage). a. Enrollment Worksheet, INCLUDING DEMOGRAPHICS ON LAST PAGE! b. Optima Health Application, if making changes or enrolling for the first time c. Guardian Application, if making changes or enrolling for the first time Complete the following forms to obtain your total payroll deductions. Return this form and all enrollment applications to the office no later than 4/17/15 If you have any questions, please contact Blade Benefit Consulting at 757-544-9130

F3 Manufacturing Guy’s Upholstery2601 Reliance DriveSuite 104Virginia Beach, VA 23452

ENROLLMENT WORKSHEET

Step 1Please circle the appropriate MEDICAL, DENTAL & VISION coverage you wish to enroll.

Employee Name:

Circle this box to

WAIVE cov-erage

Employee Only

Employee + Spouse

Employee + Child

Employee + Children Family Bi-Weekly

Cost

Optima Vantage

1250/20/80WAIVE Elect Elect Elect Elect Elect

Guardian PPO

DentalWAIVE $20.08 $40.75 $49.19 $49.19 $71.96

Guardian Vision WAIVE $3.09 $5.21 $5.31 $5.31 $8.41

Total

F3 Manufacturing Guy’s Upholstery2601 Reliance DriveSuite 104Virginia Beach, VA 23452

F3 Manufacturing and I hereby agree that my cash compensation will be reduced by the amount of my required con-tribution for the benefit option(s) I have elected under F3 Manufacturing. This shall be effective the first pay period of the new plan year and will continue for each succeeding pay period until this agreement is amended or terminated. Any previous election and compensation reduction agreement under the F3 Manufacturing relating to the same benefit(s) is hereby revoked. By signing below, you acknowledge you have been given the enrollment booklet and understand the benefit options available.

Address:

City, State, Zip:

Signature: Date:

Step 2Please mark (/) next to the FLEXIBLE SPENDING ACCOUNT and/or DEPENDENT CARE ACCOUNT that you

wish to enroll. Please be sure to write in your ANNUAL ELECTION.

Annual Election

÷ 26 =

Bi-Weekly DeductionFlexible Spending Account

(max of $2,500) WAIVE ELECT $ $

Dependent Care Account (max of $5,000) WAIVE ELECT $ $

(3) Total $

Complete this section ABOUT YOURSELF, SPOUSE and/or a DEPENDENT(S).

Employee

Name Social Security Number Date of Birth Sex (M or F)

Enroll in Dental? YES NO

Enroll in Vision? YES NO

Spouse

Name Social Security Number Date of Birth Sex (M or F)

Enroll in Dental? YES NO

Enroll in Vision? YES NO

Child

Name Social Security Number Date of Birth Sex (M or F)

Enroll in Dental? YES NO

Enroll in Vision? YES NO

Child

Name Social Security Number Date of Birth Sex (M or F)

Enroll in Dental? YES NO

Enroll in Vision? YES NO

ENROLLMENT WORKSHEETEmployee Name:

DEMOGRAPHIC INFORMATION

Please complete this section on YOURSELF, YOUR SPOUSE AND/OR YOUR CHILDREN. PLEASE PRINT.If additional dependents are needed, please list on a separate sheet.

F3 Manufacturing Guy’s Upholstery2601 Reliance DriveSuite 104Virginia Beach, VA 23452

Step 3

4417 Corporation LaneVirginia Beach, VA 23462

1

X1250/20/80

X

F3 Manufacturing

4417 Corporation LaneVirginia Beach, VA 23462

2

4417 Corporation LaneVirginia Beach, VA 23462

3

4417 Corporation LaneVirginia Beach, VA 23462

4

4417 Corporation LaneVirginia Beach, VA 23462

5

4417 Corporation LaneVirginia Beach, VA 23462

6

4417 Corporation LaneVirginia Beach, VA 23462

7

W. Brandon Beavers

4417 Corporation LaneVirginia Beach, VA 23462

8