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Employee s Signature Date CH QE EBS USE ONLY KEYED BY AUDITED BY KEYED DATE AUDITED DATE 102-205 Rev 12/2016 PREMIUM WAIVER BENEFITS REP EFFECTIVE DATE FELONIOUS ASSAULT- FA1 Bus Drivers HAZARDOUS OCC- HO1 Security Guards/Park Rangers 2017 BI-WEEKLY PAYROLL DEDUCTIONS TIER OF COVERAGE HEALTH SAVINGS ACCOUNT HSA CONTRIBUTION GUIDELINES HEALTH REIMBURSEMENT ACCOUNT HRA ANNUAL ALLOCATION Employee Only County Funded Employee Spouse Employee Contribution Under age 55 pretax Total 2017...

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