Page 22 - 2015 OE Sample Guidebook

2014 EMPLOYEE CONTRIBUTIONS

Optional Vision Care—VSP Optional Term Life Insurance

Coverage Monthly Cost Monthly Cost Per $1,000 Of Coverage
Employee Only $ Age Employee Spouse
Employee + Children $ Under 30 $ $
Employee + Spouse $ 30-34 $ $
Family $ 35-39 $ $
40-44 $ $
45-49 $ $
50-54 $ $
55-59 $ $
60-64 $ $
65-69 $ $
70-74 $ $
75-79 $ $
80+ $ $
Dependent Children Coverage Amount Monthly Cost
Option 1 $5,000 $
Option 2 $10,000 $

Example

Bill is 42 years old and his wife is 38. Bill elects $40,000 in
Optional Life Insurance for himself and $20,000 for his wife.
Here’s how his monthly cost is determined:

For Bill 40 x $____ = $
For Bill’s wife 20 x $____ = $
TOTAL $____ PER MONTH

Voluntary AD&D Insurance

Coverage Monthly Cost Per $1,000 of Coverage
Employee $
Employee + Family $

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