Page 39 - Applied Plastics - Post Enrollment Binder

Deductions per year: 52 These rates were prepared on 6/21/2021 and are valid for 90 days.

Individual Disability - ISTD3000 for WI AA Risk Class Applicable to policy form Individual Disability
l Off Job Accident & Off Job Sickness
3 Month Benefit Period
ELIMINATION PERIOD ISSUE AGE $1,200* $1,400* $1,600* $1,800* $2,000*
0 days Accident/7 days Sickness 17-49 $8.17 $9.53 $10.89 $12.25 $13.62
50-64 $9.69 $11.31 $12.92 $14.54 $16.15
65-74 $11.33 $13.21 $15.10 $16.99 $18.88
0 days Accident/14 days Sickness 17-49 $5.82 $6.78 $7.75 $8.72 $9.69
50-64 $6.81 $7.95 $9.08 $10.22 $11.35
65-74 $8.70 $10.14 $11.59 $13.04 $14.49
*monthly benefit amount
6 Month Benefit Period
ELIMINATION PERIOD ISSUE AGE $1,200* $1,400* $1,600* $1,800* $2,000*
0 days Accident/7 days Sickness 17-49 $10.25 $11.95 $13.66 $15.37 $17.08
50-64 $13.29 $15.51 $17.72 $19.94 $22.15
65-74 $17.28 $20.16 $23.04 $25.92 $28.80
0 days Accident/14 days Sickness 17-49 $7.53 $8.79 $10.04 $11.30 $12.55
50-64 $9.69 $11.31 $12.92 $14.54 $16.15
65-74 $12.46 $14.54 $16.62 $18.69 $20.77
*monthly benefit amount

Individual Accident (IAC4000) for WI Applicable to Policy Forms IAC4000
l Off-Job Accident Coverage, Wellbeing Assistance Standard - $100
BENEFIT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY
Preferred 0-80 $5.07 $7.68 $7.76 $10.26

Individual Medical Bridge for WI Applicable to policy form Individual Medical Bridge
l $3000 Hospital Confinement Benefit and Outpatient Surgical Procedure Benefit with a calendar year maximum of $1500.
ISSUE AGE EMPLOYEE EMPLOYEE AND SPOUSE EMPLOYEE AND DEPENDENT EMPLOYEE, SPOUSE AND
CHILDREN DEPENDENT CHILDREN
17-49 $10.43 $19.79 $14.47 $23.83
50-59 $14.56 $27.70 $18.60 $31.73
60-64 $19.60 $37.21 $23.63 $41.25
65-75 $25.73 $48.86 $29.77 $52.89

Individual Medical Bridge for WI Applicable to policy form Individual Medical Bridge
l $3000 Hospital Confinement Benefit and Outpatient Surgical Procedure Benefit with a calendar year maximum of $1500.
Daily Hospital Confinement benefit, Enhanced Intensive Care Unit Confinement benefit
ISSUE AGE EMPLOYEE EMPLOYEE AND SPOUSE EMPLOYEE AND DEPENDENT EMPLOYEE, SPOUSE AND
CHILDREN DEPENDENT CHILDREN
17-49 $12.91 $24.50 $17.93 $29.52
50-59 $17.47 $33.23 $22.49 $38.24
60-64 $23.81 $45.21 $28.82 $50.24

Underwritten by Colonial Life & Accident Insurance Company
Page 1 of 3 See page 3 for Important Notice