| |
Annual premium amount for the
treatment / insurance I1 |
2500.00
|
|
| |
Do you want to prorate the annual
premium amount paid ? I2 |
Yes
|
|
| |
Pro-rated annual premium for treatment
/ insurance for the tax year I3 |
95.89
|
|
| |
Amount made good by employee or
amount subjected to tax I4 |
0.00
|
|
| |
Total Cash Equivalent
Amount ( I3 minus I4 ) I |
95.89
|
|