COVER PAGE - New Mexico Children, Youth, and Families ...

New Mexico Employees Health Coverage Form (Pass/Fail) ... PERA Building, Room 101. 1120 Paseo De Peralta. Santa Fe, NM 87501. To the Contractor: ... EMPLOYEE LIABILITY INSURANCE PREMIUM $ RETIREE HEALTH CARE CONTRIBUTION $ OTHER EMPLOYEE BENEFITS $ TOTAL $ _____ OTHER COSTS CATEGORY ... ................
................