11/15/23, 8:13 PM New Elections

New Elections, Confirmation

Statement for Chandra Bhushan Nirala
Your Benefits as of 1/1/2024

TOTAL COSTS PER PAY PERIOD TOTAL COSTS PER YEAR

Your Cost $317.79 Employer Cost $17,003.76

Employer Cost $708.50

https://secure.bswift.com/benefit/enrollment.aspx 1/5
11/15/23, 8:13 PM New Elections

 Surcharges

Your Surcharges

Employee

✔ Wellness Surcharge $0.00 Per Pay Period

✔ Spouse Wellness Surcharge $0.00 Per Pay Period

Your Surcharges

Employee

× Tobacco User Surcharge $0.00 Per Pay Period

× Spouse Tobacco Surcharge $0.00 Per Pay Period

× Working Spouse Surcharge $0.00 Per Pay Period

 Medical Your cost per pay period $182.00

Green Option Cost Details Per Pay Period

Coverage: Employee + Family
Total Premium $883.71
Effective Date : 1/1/2024 - 12/31/2024
Employer Contribution ($701.71)
Your Cost $182.00
Who will be covered on this plan:
Name Relationship Coverage Effective Date

Chandra Bhushan Nirala Employee Covered 11/1/2023

Kirti Kumari Spouse Covered 1/1/2024

Gauransh Sharma Child Covered 1/1/2024

Dental Waived

Waived

https://secure.bswift.com/benefit/enrollment.aspx 2/5
11/15/23, 8:13 PM New Elections

 Vision Your cost per pay period $6.14

Vision Plan Cost Details Per Pay Period

Coverage: Employee + Spouse
Total Premium $6.14
Effective Date : 1/1/2024
Employer Contribution $0.00
Your Cost $6.14
Who will be covered on this plan:
Name Relationship Coverage Effective Date

Chandra Bhushan Nirala Employee Covered 1/1/2024

Kirti Kumari Spouse Covered 1/1/2024

Gauransh Sharma Child Waived 11/1/2023

 FSA Health Your cost per pay period $127.08

Health Care Flexible Spending Account 2024 Cost Details Per Pay Period
Contribution: $3,050.00 per year
Total Premium $127.08
Effective Date : 1/1/2024 - 12/31/2024
Employer Contribution $0.00
Your Cost $127.08

FSA Dependent Care Waived

Waived

 Accident Insurance Your cost per pay period $2.57

Accident Insurance Cost Details Per Pay Period

Coverage: Employee
Total Premium $2.57
Effective Date : 11/1/2023
Employer Contribution $0.00
Your Cost $2.57
Who will be covered on this plan:
Name Relationship Coverage Effective Date

Chandra Bhushan Nirala Employee Covered 11/1/2023

Kirti Kumari Spouse Waived 11/1/2023

Gauransh Sharma Child Waived 11/1/2023

https://secure.bswift.com/benefit/enrollment.aspx 3/5
11/15/23, 8:13 PM New Elections

Critical Illness – Employee Waived

Waived

Critical Illness – Spouse Waived

Waived

Critical Illness – Child(ren) Waived

Waived

 Basic Employee Life/AD&D Your cost per pay period $0.00

1 x Basic Annual Earnings Cost Details Per Pay Period

Coverage: 1 X Pay
Total Premium $5.04
Coverage Amount: $140,000.00
Employer Contribution ($5.04)
Effective Date : 11/1/2023
Your Cost $0.00

Beneficiaries:
Name Relationship Primary Secondary

Kirti Kumari Spouse 100.0% —

Supplemental Employee Life/AD&D Waived

Waived

Supplemental Dependent Life Waived

Waived

https://secure.bswift.com/benefit/enrollment.aspx 4/5
11/15/23, 8:13 PM New Elections

 Short Term Disability (STD) Your cost per pay period $0.00

Short Term Disability Cost Details Per Pay Period

Effective Date : 11/1/2023
Total Premium $1.26
Employer Contribution ($1.26)
Your Cost $0.00

Long Term Disability Waived

Waived

 Employee Assistance Program Your cost per pay period $0.00

Employee Assistance Program Cost Details Per Pay Period

Effective Date : 11/1/2023
Total Premium $0.49
Employer Contribution ($0.49)
Your Cost $0.00

Legal Services Waived

Waived

$1,026.29
Totals Per Pay Period Total Premium

Employer Contribution ($708.50)

Your Cost $317.79

Your Confirmation Number is: 28989812

Created on: 11/15/2023

https://secure.bswift.com/benefit/enrollment.aspx 5/5