Premium Table VG Undffrntd - Reliance Standard



First Reliance Standard Insurance PlansDependent Life InsuranceSupplemental Life Insurance Premium TablePlan Holder: Supplemental Life Insurance Premium TableScheduled Benefit: Each eligible employee may elect for himself/herself an amount of insurance shown in the Table below. Benefit amounts are reduced according to the age-based reduction chart shown in the Supplemental Life brochure.Employee Premiums:To find your premium -Determine your age band: Your age is calculated by the method specified in your policy.Select a benefit amount.Employee rates change as insured moves from one age bracket to the next.Employee Bi-Weekly Premiums – Non-SmokerBenefit AmountAge 18-24Age 25-29Age 30-34Age 35-39Age 40-44Age 45-49Age 50-54Age 55-59Age 60-64Age 65-69Age 70-74Age 75-79Age 80+$10,000$0.40$0.50$0.70$0.80$0.90$1.40$2.20$4.20$5.90$12.50$23.70$69.30$152.00$20,000$0.80$1.00$1.40$1.60$1.80$2.80$4.40$8.40$11.80$25.00$47.40$138.60$304.00$30,000$1.20$1.50$2.10$2.40$2.70$4.20$6.60$12.60$17.70$37.50$71.10$207.90$456.00$40,000$1.60$2.00$2.80$3.20$3.60$5.60$8.80$16.80$23.60$50.00$94.80$277.20$608.00$50,000$2.00$2.50$3.50$4.00$4.50$7.00$11.00$21.00$29.50$62.50$118.50$346.50$760.00$60,000$2.40$3.00$4.20$4.80$5.40$8.40$13.20$25.20$35.40$75.00$142.20$415.80$912.00$70,000$2.80$3.50$4.90$5.60$6.30$9.80$15.40$29.40$41.30$87.50$165.90$485.10$1,064.00$80,000$3.20$4.00$5.60$6.40$7.20$11.20$17.60$33.60$47.20$100.00$189.60$554.40$1,216.00$90,000$3.60$4.50$6.30$7.20$8.10$12.60$19.80$37.80$53.10$112.50$213.30$623.70$1,368.00$100,000$4.00$5.00$7.00$8.00$9.00$14.00$22.00$42.00$59.00$125.00$237.00$693.00$1,520.00$110,000$4.40$5.50$7.70$8.80$9.90$15.40$24.20$46.20$64.90$137.50$260.70$762.30$1,672.00$120,000$4.80$6.00$8.40$9.60$10.80$16.80$26.40$50.40$70.80$150.00$284.40$831.60$1,824.00$130,000$5.20$6.50$9.10$10.40$11.70$18.20$28.60$54.60$76.70$162.50$308.10$900.90$1,976.00$140,000$5.60$7.00$9.80$11.20$12.60$19.60$30.80$58.80$82.60$175.00$331.80$970.20$2,128.00$150,000$6.00$7.50$10.50$12.00$13.50$21.00$33.00$63.00$88.50$187.50$355.50$1,039.50$2,280.00$160,000$6.40$8.00$11.20$12.80$14.40$22.40$35.20$67.20$94.40$200.00$379.20$1,108.80$2,432.00$170,000$6.80$8.50$11.90$13.60$15.30$23.80$37.40$71.40$100.30$212.50$402.90$1,178.10$2,584.00$180,000$7.20$9.00$12.60$14.40$16.20$25.20$39.60$75.60$106.20$225.00$426.60$1,247.40$2,736.00$190,000$7.60$9.50$13.30$15.20$17.10$26.60$41.80$79.80$112.10$237.50$450.30$1,316.70$2,888.00$200,000$8.00$10.00$14.00$16.00$18.00$28.00$44.00$84.00$118.00$250.00$474.00$1,386.00$3,040.00$210,000$8.40$10.50$14.70$16.80$18.90$29.40$46.20$88.20$123.90$262.50$497.70$1,455.30$3,192.00$220,000$8.80$11.00$15.40$17.60$19.80$30.80$48.40$92.40$129.80$275.00$521.40$1,524.60$3,344.00$230,000$9.20$11.50$16.10$18.40$20.70$32.20$50.60$96.60$135.70$287.50$545.10$1,593.90$3,496.00$240,000$9.60$12.00$16.80$19.20$21.60$33.60$52.80$100.80$141.60$300.00$568.80$1,663.20$3,648.00$250,000$10.00$12.50$17.50$20.00$22.50$35.00$55.00$105.00$147.50$312.50$592.50$1,732.50$3,800.00$260,000$10.40$13.00$18.20$20.80$23.40$36.40$57.20$109.20$153.40$325.00$616.20$1,801.80$3,952.00$270,000$10.80$13.50$18.90$21.60$24.30$37.80$59.40$113.40$159.30$337.50$639.90$1,871.10$4,104.00$280,000$11.20$14.00$19.60$22.40$25.20$39.20$61.60$117.60$165.20$350.00$663.60$1,940.40$4,256.00$290,000$11.60$14.50$20.30$23.20$26.10$40.60$63.80$121.80$171.10$362.50$687.30$2,009.70$4,408.00$300,000$12.00$15.00$21.00$24.00$27.00$42.00$66.00$126.00$177.00$375.00$711.00$2,079.00$4,560.00$310,000$12.40$15.50$21.70$24.80$27.90$43.40$68.20$130.20$182.90$387.50$734.70$2,148.30$4,712.00$320,000$12.80$16.00$22.40$25.60$28.80$44.80$70.40$134.40$188.80$400.00$758.40$2,217.60$4,864.00$330,000$13.20$16.50$23.10$26.40$29.70$46.20$72.60$138.60$194.70$412.50$782.10$2,286.90$5,016.00$340,000$13.60$17.00$23.80$27.20$30.60$47.60$74.80$142.80$200.60$425.00$805.80$2,356.20$5,168.00$350,000$14.00$17.50$24.50$28.00$31.50$49.00$77.00$147.00$206.50$437.50$829.50$2,425.50$5,320.00$360,000$14.40$18.00$25.20$28.80$32.40$50.40$79.20$151.20$212.40$450.00$853.20$2,494.80$5,472.00$370,000$14.80$18.50$25.90$29.60$33.30$51.80$81.40$155.40$218.30$462.50$876.90$2,564.10$5,624.00$380,000$15.20$19.00$26.60$30.40$34.20$53.20$83.60$159.60$224.20$475.00$900.60$2,633.40$5,776.00$390,000$15.60$19.50$27.30$31.20$35.10$54.60$85.80$163.80$230.10$487.50$924.30$2,702.70$5,928.00$400,000$16.00$20.00$28.00$32.00$36.00$56.00$88.00$168.00$236.00$500.00$948.00$2,772.00$6,080.00$410,000$16.40$20.50$28.70$32.80$36.90$57.40$90.20$172.20$241.90$512.50$971.70$2,841.30$6,232.00$420,000$16.80$21.00$29.40$33.60$37.80$58.80$92.40$176.40$247.80$525.00$995.40$2,910.60$6,384.00$430,000$17.20$21.50$30.10$34.40$38.70$60.20$94.60$180.60$253.70$537.50$1,019.10$2,979.90$6,536.00$440,000$17.60$22.00$30.80$35.20$39.60$61.60$96.80$184.80$259.60$550.00$1,042.80$3,049.20$6,688.00$450,000$18.00$22.50$31.50$36.00$40.50$63.00$99.00$189.00$265.50$562.50$1,066.50$3,118.50$6,840.00$460,000$18.40$23.00$32.20$36.80$41.40$64.40$101.20$193.20$271.40$575.00$1,090.20$3,187.80$6,992.00$470,000$18.80$23.50$32.90$37.60$42.30$65.80$103.40$197.40$277.30$587.50$1,113.90$3,257.10$7,144.00$480,000$19.20$24.00$33.60$38.40$43.20$67.20$105.60$201.60$283.20$600.00$1,137.60$3,326.40$7,296.00$490,000$19.60$24.50$34.30$39.20$44.10$68.60$107.80$205.80$289.10$612.50$1,161.30$3,395.70$7,448.00$500,000$20.00$25.00$35.00$40.00$45.00$70.00$110.00$210.00$295.00$625.00$1,185.00$3,465.00$7,600.00Employee Bi-Weekly Premiums – SmokerBenefit Amount Age 18-24Age 25-29Age 30-34Age 35-39Age 40-44Age 45-49Age 50-54Age 55-59Age 60-64Age 65-69Age 70-74Age 75-79Age 80+$10,000$0.90$0.90$0.90$1.50$2.60$4.00$7.40$11.00$11.10$19.10$36.30$104.00$227.90$20,000$1.80$1.80$1.80$3.00$5.20$8.00$14.80$22.00$22.20$38.20$72.60$208.00$455.80$30,000$2.70$2.70$2.70$4.50$7.80$12.00$22.20$33.00$33.30$57.30$108.90$312.00$683.70$40,000$3.60$3.60$3.60$6.00$10.40$16.00$29.60$44.00$44.40$76.40$145.20$416.00$911.60$50,000$4.50$4.50$4.50$7.50$13.00$20.00$37.00$55.00$55.50$95.50$181.50$520.00$1,139.50$60,000$5.40$5.40$5.40$9.00$15.60$24.00$44.40$66.00$66.60$114.60$217.80$624.00$1,367.40$70,000$6.30$6.30$6.30$10.50$18.20$28.00$51.80$77.00$77.70$133.70$254.10$728.00$1,595.30$80,000$7.20$7.20$7.20$12.00$20.80$32.00$59.20$88.00$88.80$152.80$290.40$832.00$1,823.20$90,000$8.10$8.10$8.10$13.50$23.40$36.00$66.60$99.00$99.90$171.90$326.70$936.00$2,051.10$100,000$9.00$9.00$9.00$15.00$26.00$40.00$74.00$110.00$111.00$191.00$363.00$1,040.00$2,279.00$110,000$9.90$9.90$9.90$16.50$28.60$44.00$81.40$121.00$122.10$210.10$399.30$1,144.00$2,506.90$120,000$10.80$10.80$10.80$18.00$31.20$48.00$88.80$132.00$133.20$229.20$435.60$1,248.00$2,734.80$130,000$11.70$11.70$11.70$19.50$33.80$52.00$96.20$143.00$144.30$248.30$471.90$1,352.00$2,962.70$140,000$12.60$12.60$12.60$21.00$36.40$56.00$103.60$154.00$155.40$267.40$508.20$1,456.00$3,190.60$150,000$13.50$13.50$13.50$22.50$39.00$60.00$111.00$165.00$166.50$286.50$544.50$1,560.00$3,418.50$160,000$14.40$14.40$14.40$24.00$41.60$64.00$118.40$176.00$177.60$305.60$580.80$1,664.00$3,646.40$170,000$15.30$15.30$15.30$25.50$44.20$68.00$125.80$187.00$188.70$324.70$617.10$1,768.00$3,874.30$180,000$16.20$16.20$16.20$27.00$46.80$72.00$133.20$198.00$199.80$343.80$653.40$1,872.00$4,102.20$190,000$17.10$17.10$17.10$28.50$49.40$76.00$140.60$209.00$210.90$362.90$689.70$1,976.00$4,330.10$200,000$18.00$18.00$18.00$30.00$52.00$80.00$148.00$220.00$222.00$382.00$726.00$2,080.00$4,558.00$210,000$18.90$18.90$18.90$31.50$54.60$84.00$155.40$231.00$233.10$401.10$762.30$2,184.00$4,785.90$220,000$19.80$19.80$19.80$33.00$57.20$88.00$162.80$242.00$244.20$420.20$798.60$2,288.00$5,013.80$230,000$20.70$20.70$20.70$34.50$59.80$92.00$170.20$253.00$255.30$439.30$834.90$2,392.00$5,241.70$240,000$21.60$21.60$21.60$36.00$62.40$96.00$177.60$264.00$266.40$458.40$871.20$2,496.00$5,469.60$250,000$22.50$22.50$22.50$37.50$65.00$100.00$185.00$275.00$277.50$477.50$907.50$2,600.00$5,697.50$260,000$23.40$23.40$23.40$39.00$67.60$104.00$192.40$286.00$288.60$496.60$943.80$2,704.00$5,925.40$270,000$24.30$24.30$24.30$40.50$70.20$108.00$199.80$297.00$299.70$515.70$980.10$2,808.00$6,153.30$280,000$25.20$25.20$25.20$42.00$72.80$112.00$207.20$308.00$310.80$534.80$1,016.40$2,912.00$6,381.20$290,000$26.10$26.10$26.10$43.50$75.40$116.00$214.60$319.00$321.90$553.90$1,052.70$3,016.00$6,609.10$300,000$27.00$27.00$27.00$45.00$78.00$120.00$222.00$330.00$333.00$573.00$1,089.00$3,120.00$6,837.00$310,000$27.90$27.90$27.90$46.50$80.60$124.00$229.40$341.00$344.10$592.10$1,125.30$3,224.00$7,064.90$320,000$28.80$28.80$28.80$48.00$83.20$128.00$236.80$352.00$355.20$611.20$1,161.60$3,328.00$7,292.80$330,000$29.70$29.70$29.70$49.50$85.80$132.00$244.20$363.00$366.30$630.30$1,197.90$3,432.00$7,520.70$340,000$30.60$30.60$30.60$51.00$88.40$136.00$251.60$374.00$377.40$649.40$1,234.20$3,536.00$7,748.60$350,000$31.50$31.50$31.50$52.50$91.00$140.00$259.00$385.00$388.50$668.50$1,270.50$3,640.00$7,976.50$360,000$32.40$32.40$32.40$54.00$93.60$144.00$266.40$396.00$399.60$687.60$1,306.80$3,744.00$8,204.40$370,000$33.30$33.30$33.30$55.50$96.20$148.00$273.80$407.00$410.70$706.70$1,343.10$3,848.00$8,432.30$380,000$34.20$34.20$34.20$57.00$98.80$152.00$281.20$418.00$421.80$725.80$1,379.40$3,952.00$8,660.20$390,000$35.10$35.10$35.10$58.50$101.40$156.00$288.60$429.00$432.90$744.90$1,415.70$4,056.00$8,888.10$400,000$36.00$36.00$36.00$60.00$104.00$160.00$296.00$440.00$444.00$764.00$1,452.00$4,160.00$9,116.00$410,000$36.90$36.90$36.90$61.50$106.60$164.00$303.40$451.00$455.10$783.10$1,488.30$4,264.00$9,343.90$420,000$37.80$37.80$37.80$63.00$109.20$168.00$310.80$462.00$466.20$802.20$1,524.60$4,368.00$9,571.80$430,000$38.70$38.70$38.70$64.50$111.80$172.00$318.20$473.00$477.30$821.30$1,560.90$4,472.00$9,799.70$440,000$39.60$39.60$39.60$66.00$114.40$176.00$325.60$484.00$488.40$840.40$1,597.20$4,576.00$10,027.60$450,000$40.50$40.50$40.50$67.50$117.00$180.00$333.00$495.00$499.50$859.50$1,633.50$4,680.00$10,255.50$460,000$41.40$41.40$41.40$69.00$119.60$184.00$340.40$506.00$510.60$878.60$1,669.80$4,784.00$10,483.40$470,000$42.30$42.30$42.30$70.50$122.20$188.00$347.80$517.00$521.70$897.70$1,706.10$4,888.00$10,711.30$480,000$43.20$43.20$43.20$72.00$124.80$192.00$355.20$528.00$532.80$916.80$1,742.40$4,992.00$10,939.20$490,000$44.10$44.10$44.10$73.50$127.40$196.00$362.60$539.00$543.90$935.90$1,778.70$5,096.00$11,167.10$500,000$45.00$45.00$45.00$75.00$130.00$200.00$370.00$550.00$555.00$955.00$1,815.00$5,200.00$11,395.00 Dependent Life Insurance Premium TableScheduled Benefit: Each eligible employee may elect for his/her eligible spouse an amount of insurance shown in the Table below.Benefit amounts are reduced according to the age-based reduction chart shown in the Dependent Life policy.To find your spouse’s premium –Determine your spouse's age band. Spouse’s age is equal to the employee’s age.Select a benefit.Spouse rates change as employee moves from one age bracket to the next.Spouse Bi-Weekly Premiums – Non-SmokerBenefit AmountAge 18-24Age 25-29Age 30-34Age 35-39Age 40-44Age 45-49Age 50-54Age 55-59Age 60-64Age 65-69Age 70-74Age 75-79Age 80+$5,000$0.20$0.25$0.35$0.40$0.45$0.70$1.10$2.10$2.95$6.25$11.85$34.65$76.00$10,000$0.40$0.50$0.70$0.80$0.90$1.40$2.20$4.20$5.90$12.50$23.70$69.30$152.00$15,000$0.60$0.75$1.05$1.20$1.35$2.10$3.30$6.30$8.85$18.75$35.55$103.95$228.00$20,000$0.80$1.00$1.40$1.60$1.80$2.80$4.40$8.40$11.80$25.00$47.40$138.60$304.00$25,000$1.00$1.25$1.75$2.00$2.25$3.50$5.50$10.50$14.75$31.25$59.25$173.25$380.00$30,000$1.20$1.50$2.10$2.40$2.70$4.20$6.60$12.60$17.70$37.50$71.10$207.90$456.00$35,000$1.40$1.75$2.45$2.80$3.15$4.90$7.70$14.70$20.65$43.75$82.95$242.55$532.00$40,000$1.60$2.00$2.80$3.20$3.60$5.60$8.80$16.80$23.60$50.00$94.80$277.20$608.00$45,000$1.80$2.25$3.15$3.60$4.05$6.30$9.90$18.90$26.55$56.25$106.65$311.85$684.00$50,000$2.00$2.50$3.50$4.00$4.50$7.00$11.00$21.00$29.50$62.50$118.50$346.50$760.00$55,000$2.20$2.75$3.85$4.40$4.95$7.70$12.10$23.10$32.45$68.75$130.35$381.15$836.00$60,000$2.40$3.00$4.20$4.80$5.40$8.40$13.20$25.20$35.40$75.00$142.20$415.80$912.00$65,000$2.60$3.25$4.55$5.20$5.85$9.10$14.30$27.30$38.35$81.25$154.05$450.45$988.00$70,000$2.80$3.50$4.90$5.60$6.30$9.80$15.40$29.40$41.30$87.50$165.90$485.10$1,064.00$75,000$3.00$3.75$5.25$6.00$6.75$10.50$16.50$31.50$44.25$93.75$177.75$519.75$1,140.00$80,000$3.20$4.00$5.60$6.40$7.20$11.20$17.60$33.60$47.20$100.00$189.60$554.40$1,216.00$85,000$3.40$4.25$5.95$6.80$7.65$11.90$18.70$35.70$50.15$106.25$201.45$589.05$1,292.00$90,000$3.60$4.50$6.30$7.20$8.10$12.60$19.80$37.80$53.10$112.50$213.30$623.70$1,368.00$95,000$3.80$4.75$6.65$7.60$8.55$13.30$20.90$39.90$56.05$118.75$225.15$658.35$1,444.00$100,000$4.00$5.00$7.00$8.00$9.00$14.00$22.00$42.00$59.00$125.00$237.00$693.00$1,520.00$105,000$4.20$5.25$7.35$8.40$9.45$14.70$23.10$44.10$61.95$131.25$248.85$727.65$1,596.00$110,000$4.40$5.50$7.70$8.80$9.90$15.40$24.20$46.20$64.90$137.50$260.70$762.30$1,672.00$115,000$4.60$5.75$8.05$9.20$10.35$16.10$25.30$48.30$67.85$143.75$272.55$796.95$1,748.00$120,000$4.80$6.00$8.40$9.60$10.80$16.80$26.40$50.40$70.80$150.00$284.40$831.60$1,824.00$125,000$5.00$6.25$8.75$10.00$11.25$17.50$27.50$52.50$73.75$156.25$296.25$866.25$1,900.00$130,000$5.20$6.50$9.10$10.40$11.70$18.20$28.60$54.60$76.70$162.50$308.10$900.90$1,976.00$135,000$5.40$6.75$9.45$10.80$12.15$18.90$29.70$56.70$79.65$168.75$319.95$935.55$2,052.00$140,000$5.60$7.00$9.80$11.20$12.60$19.60$30.80$58.80$82.60$175.00$331.80$970.20$2,128.00$145,000$5.80$7.25$10.15$11.60$13.05$20.30$31.90$60.90$85.55$181.25$343.65$1,004.85$2,204.00$150,000$6.00$7.50$10.50$12.00$13.50$21.00$33.00$63.00$88.50$187.50$355.50$1,039.50$2,280.00Spouse Bi-Weekly Premiums – SmokerBenefit AmountAge 18-24Age 25-29Age 30-34Age 35-39Age 40-44Age 45-49Age 50-54Age 55-59Age 60-64Age 65-69Age 70-74Age 75-79Age 80+$5,000$0.45$0.45$0.45$0.75$1.30$2.00$3.70$5.50$5.55$9.55$18.15$52.00$113.95$10,000$0.90$0.90$0.90$1.50$2.60$4.00$7.40$11.00$11.10$19.10$36.30$104.00$227.90$15,000$1.35$1.35$1.35$2.25$3.90$6.00$11.10$16.50$16.65$28.65$54.45$156.00$341.85$20,000$1.80$1.80$1.80$3.00$5.20$8.00$14.80$22.00$22.20$38.20$72.60$208.00$455.80$25,000$2.25$2.25$2.25$3.75$6.50$10.00$18.50$27.50$27.75$47.75$90.75$260.00$569.75$30,000$2.70$2.70$2.70$4.50$7.80$12.00$22.20$33.00$33.30$57.30$108.90$312.00$683.70$35,000$3.15$3.15$3.15$5.25$9.10$14.00$25.90$38.50$38.85$66.85$127.05$364.00$797.65$40,000$3.60$3.60$3.60$6.00$10.40$16.00$29.60$44.00$44.40$76.40$145.20$416.00$911.60$45,000$4.05$4.05$4.05$6.75$11.70$18.00$33.30$49.50$49.95$85.95$163.35$468.00$1,025.55$50,000$4.50$4.50$4.50$7.50$13.00$20.00$37.00$55.00$55.50$95.50$181.50$520.00$1,139.50$55,000$4.95$4.95$4.95$8.25$14.30$22.00$40.70$60.50$61.05$105.05$199.65$572.00$1,253.45$60,000$5.40$5.40$5.40$9.00$15.60$24.00$44.40$66.00$66.60$114.60$217.80$624.00$1,367.40$65,000$5.85$5.85$5.85$9.75$16.90$26.00$48.10$71.50$72.15$124.15$235.95$676.00$1,481.35$70,000$6.30$6.30$6.30$10.50$18.20$28.00$51.80$77.00$77.70$133.70$254.10$728.00$1,595.30$75,000$6.75$6.75$6.75$11.25$19.50$30.00$55.50$82.50$83.25$143.25$272.25$780.00$1,709.25$80,000$7.20$7.20$7.20$12.00$20.80$32.00$59.20$88.00$88.80$152.80$290.40$832.00$1,823.20$85,000$7.65$7.65$7.65$12.75$22.10$34.00$62.90$93.50$94.35$162.35$308.55$884.00$1,937.15$90,000$8.10$8.10$8.10$13.50$23.40$36.00$66.60$99.00$99.90$171.90$326.70$936.00$2,051.10$95,000$8.55$8.55$8.55$14.25$24.70$38.00$70.30$104.50$105.45$181.45$344.85$988.00$2,165.05$100,000$9.00$9.00$9.00$15.00$26.00$40.00$74.00$110.00$111.00$191.00$363.00$1,040.00$2,279.00$105,000$9.45$9.45$9.45$15.75$27.30$42.00$77.70$115.50$116.55$200.55$381.15$1,092.00$2,392.95$110,000$9.90$9.90$9.90$16.50$28.60$44.00$81.40$121.00$122.10$210.10$399.30$1,144.00$2,506.90$115,000$10.35$10.35$10.35$17.25$29.90$46.00$85.10$126.50$127.65$219.65$417.45$1,196.00$2,620.85$120,000$10.80$10.80$10.80$18.00$31.20$48.00$88.80$132.00$133.20$229.20$435.60$1,248.00$2,734.80$125,000$11.25$11.25$11.25$18.75$32.50$50.00$92.50$137.50$138.75$238.75$453.75$1,300.00$2,848.75$130,000$11.70$11.70$11.70$19.50$33.80$52.00$96.20$143.00$144.30$248.30$471.90$1,352.00$2,962.70$135,000$12.15$12.15$12.15$20.25$35.10$54.00$99.90$148.50$149.85$257.85$490.05$1,404.00$3,076.65$140,000$12.60$12.60$12.60$21.00$36.40$56.00$103.60$154.00$155.40$267.40$508.20$1,456.00$3,190.60$145,000$13.05$13.05$13.05$21.75$37.70$58.00$107.30$159.50$160.95$276.95$526.35$1,508.00$3,304.55$150,000$13.50$13.50$13.50$22.50$39.00$60.00$111.00$165.00$166.50$286.50$544.50$1,560.00$3,418.50Dependent Children Premiums:Benefit AmountPremium$10,000$2.00(One rate and benefit amount for all eligible children in family, regardless of number)PREMIUM CALCULATION (Add your elections here):Employee Premium Spouse PremiumDependent Children PremiumTotal Premium(Rates are calculated as of coverage effective date and are based on insured's age in relation to Plan anniversary date. Billed rates may be higher if, at application, the person is at the highest age in an age band).Please read this important information:You may not have coverage as both an employee and as a dependent.Only one insured spouse may cover the eligible dependent children.Rates are subject to change. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download