Section 125 Plan Tax Savings Calculator

How can a Section 125 Plan save you money? Complete this form to determine what a Section 125 Plan can save you every year.

Select Your Yearly Income

Select Your Pay Period

Insurance Premiums ( if payroll deducted) Enter Premium for entire Year.
Medical Insurance Premium $
$50,000 Grp Term Life Insurance $
Short Term or Long term Disability coverage $
Vision Care and Dental Insurance $
Other Supplemental Insurance $
Total $

Annual Medical Expenses (estimated)
Doctor's Office visits $
Annual Deductibles expense $
Rx Prescription drugs $
Medically necessary supplies/equipment $
Travel to physicians or treatment $
Vision exams & eye surgery $
Prescription Glasses/contacts/solutions $
Dental expenses $
Root Canals/ Cavity Fillings/ crowns $
Orthodontic Expenses $
Chiropractor $
Other $
Total $

Dependent Care Expenses for Entire Year
Dependent Children under 13 $
Incapacitated Adults $
Total $

Adoption Expenses for the Entire Year
Lawyer fees $
Court expenses $
Legal adoption expenses $
Other expenses $
Total $

Estimated Annual Expenses and Tax Savings
Total Medical Insurance Premiums $
Total Out-of-Pocket Medical Expenses $
Total Dependent Child Care Expenses $
Total Adoption Cost $
Total Annual Expenses $
Annual Tax Savings $
Estimated Savings 
Amount Per Paycheck		 $

Tax Estimate Table

If your
annual household
earnings are:

Estimated 
tax rate is:

Less than $30,000
$30,000 - $40,000
$40,000 - $70,000
Greater than $70,000

25%
29%
31%
33%

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