Employer Premium Contribution
Enrollment	Number	HDHP	Prior Plan
Employee		$	$
Employee + Spouse		$	$
Employee + Child		$	$
Family		$	$
Estimated Monthly Premium		$	$
Estimated Annual Premium		$	$
Estimated Annual Premium Savings		$
Employer HRA Contribution
Enrollment		Contribution	Total
Employee		$	$
Employee + Spouse		$	$
Employee + Child		$	$
Family		$	$
Total			$
Annual HRA Fees
Setup Fee			$
Per Member Per Month Fee		$	$
Total			$
Estimated Claims Usage
		%	$
		%	$
		%	$
Estimated Annual Savings
		%	$
		%	$
		%	$