Page 15 - Guide
P. 15
Critical Illness Coverage 2017 Beneits Enrollment
Options Spouse Coverage
Employee Coverage (Bi-Weekly Premiums) (Bi-Weekly Premiums)
Non-Tobacco Tobacco Non-Tobacco Tobacco
Age $10,000 $15,000 $20,000 $10,000 $15,000 $20,000 Age $5,000 $10,000 $5,000 $10,000
benefit
benefit
benefit
benefit
benefit benefit benefit benefit benefit benefit
< 25 $2.54 $3.25 $3.97 $2.95 $3.88 $4.80 < 25 $1.82 $2.54 $2.03 $2.95
25–29 $2.86 $3.74 $4.62 $3.60 $4.85 $6.09 25–29 $1.98 $2.86 $2.35 $3.60
30–34 $3.23 $4.29 $5.35 $4.52 $6.23 $7.94 30–34 $2.17 $3.23 $2.82 $4.52
35–39 $3.97 $5.40 $6.83 $6.46 $9.14 $11.82 35–39 $2.54 $3.97 $3.78 $6.46
40–44 $5.82 $8.17 $10.52 $10.34 $14.95 $19.57 40–44 $3.46 $5.82 $5.72 $10.34
45–49 $8.08 $11.56 $15.05 $15.69 $22.98 $30.28 45–49 $4.59 $8.08 $8.40 $15.69
50–54 $11.95 $17.38 $22.80 $23.82 $35.17 $46.52 50–54 $6.53 $11.95 $12.46 $23.82
55–59 $15.88 $23.26 $30.65 $31.62 $46.87 $62.12 55–59 $8.49 $15.88 $16.36 $31.62
60–64 $24.55 $36.28 $48.00 $48.65 $72.42 $96.18 60–64 $12.83 $24.55 $24.88 $48.65
65–69 $34.98 $51.92 $68.86 $62.22 $92.77 $123.32
70–74 $38.17 $56.70 $75.23 $64.75 $96.58 $128.40
75–79 $45.09 $67.08 $89.08 $66.88 $99.76 $132.65
80–84 $48.37 $72.00 $95.63 $71.86 $107.24 $142.62
85+ $82.20 $122.75 $163.29 $101.12 $151.13 $201.14
New—Hospital Indemnity Coverage
Hospital indemnity coverage, available through Unum, pays a beneit
when you are admitted to the hospital for a covered accident or illness.
This coverage can complement your health insurance to help you pay for Hospital Indemnity Premiums
the costs associated with planned or unexpected hospitalization. Beneits (Bi-Weekly)
are payable to you to use as you wish. It can help pay your medical Coverage Level You Pay
deductible, copays, coinsurance, or normal household expenses. Employee $9.30
X Coverage is portable which means you can take this plan with you if Employee + spouse $17.70
you no longer work for the company Employee + child(ren) $12.67
Family
X A 12-month pre-existing condition exclusion applies; see plan $21.07
document for details
Summary of Benefits*
Hospital admission $1,000 per insured per calendar year
Daily Hospital Confinement $100 per day, to a maximum of 15 days
per calendar year
Hospital Intensive Care Unit Confinement $200 per day, to a maximum of 15 days
per calendar year
* Please see your summary plan description for details.
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Options Spouse Coverage
Employee Coverage (Bi-Weekly Premiums) (Bi-Weekly Premiums)
Non-Tobacco Tobacco Non-Tobacco Tobacco
Age $10,000 $15,000 $20,000 $10,000 $15,000 $20,000 Age $5,000 $10,000 $5,000 $10,000
benefit
benefit
benefit
benefit
benefit benefit benefit benefit benefit benefit
< 25 $2.54 $3.25 $3.97 $2.95 $3.88 $4.80 < 25 $1.82 $2.54 $2.03 $2.95
25–29 $2.86 $3.74 $4.62 $3.60 $4.85 $6.09 25–29 $1.98 $2.86 $2.35 $3.60
30–34 $3.23 $4.29 $5.35 $4.52 $6.23 $7.94 30–34 $2.17 $3.23 $2.82 $4.52
35–39 $3.97 $5.40 $6.83 $6.46 $9.14 $11.82 35–39 $2.54 $3.97 $3.78 $6.46
40–44 $5.82 $8.17 $10.52 $10.34 $14.95 $19.57 40–44 $3.46 $5.82 $5.72 $10.34
45–49 $8.08 $11.56 $15.05 $15.69 $22.98 $30.28 45–49 $4.59 $8.08 $8.40 $15.69
50–54 $11.95 $17.38 $22.80 $23.82 $35.17 $46.52 50–54 $6.53 $11.95 $12.46 $23.82
55–59 $15.88 $23.26 $30.65 $31.62 $46.87 $62.12 55–59 $8.49 $15.88 $16.36 $31.62
60–64 $24.55 $36.28 $48.00 $48.65 $72.42 $96.18 60–64 $12.83 $24.55 $24.88 $48.65
65–69 $34.98 $51.92 $68.86 $62.22 $92.77 $123.32
70–74 $38.17 $56.70 $75.23 $64.75 $96.58 $128.40
75–79 $45.09 $67.08 $89.08 $66.88 $99.76 $132.65
80–84 $48.37 $72.00 $95.63 $71.86 $107.24 $142.62
85+ $82.20 $122.75 $163.29 $101.12 $151.13 $201.14
New—Hospital Indemnity Coverage
Hospital indemnity coverage, available through Unum, pays a beneit
when you are admitted to the hospital for a covered accident or illness.
This coverage can complement your health insurance to help you pay for Hospital Indemnity Premiums
the costs associated with planned or unexpected hospitalization. Beneits (Bi-Weekly)
are payable to you to use as you wish. It can help pay your medical Coverage Level You Pay
deductible, copays, coinsurance, or normal household expenses. Employee $9.30
X Coverage is portable which means you can take this plan with you if Employee + spouse $17.70
you no longer work for the company Employee + child(ren) $12.67
Family
X A 12-month pre-existing condition exclusion applies; see plan $21.07
document for details
Summary of Benefits*
Hospital admission $1,000 per insured per calendar year
Daily Hospital Confinement $100 per day, to a maximum of 15 days
per calendar year
Hospital Intensive Care Unit Confinement $200 per day, to a maximum of 15 days
per calendar year
* Please see your summary plan description for details.
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