Page 40 - Applied Plastics - Post Enrollment Binder

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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
65-75 $31.53 $59.89 $36.56 $64.91

Critical Illness 1.0 for WI Applicable to policy form CI-1.0
l with Subsequent Diagnosis Coverage, Cancer Benefit
Non-Tobacco Rates
ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY
$10,000 17-24 $0.95 $1.43 $1.32 $1.82
25-29 $1.41 $2.15 $1.78 $2.54
30-34 $1.89 $2.88 $2.26 $3.28
35-39 $2.61 $3.99 $2.98 $4.38
40-44 $3.23 $4.94 $3.60 $5.33
45-49 $4.36 $6.72 $4.75 $7.08
50-54 $6.23 $9.58 $6.60 $9.95
55-59 $7.78 $11.95 $8.17 $12.35
60-64 $10.45 $16.06 $10.85 $16.45
65-70 $11.63 $17.88 $12.02 $18.25
$20,000 17-24 $1.89 $2.86 $2.63 $3.65
25-29 $2.82 $4.29 $3.55 $5.08
30-34 $3.78 $5.77 $4.52 $6.55
35-39 $5.22 $7.98 $5.95 $8.77
40-44 $6.46 $9.88 $7.20 $10.66
45-49 $8.72 $13.43 $9.51 $14.17
50-54 $12.46 $19.15 $13.20 $19.89
55-59 $15.55 $23.91 $16.34 $24.69
60-64 $20.91 $32.12 $21.69 $32.91
65-70 $23.26 $35.77 $24.05 $36.51

Tobacco Rates
ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY
$10,000 17-24 $1.34 $2.05 $1.73 $2.45
25-29 $2.10 $3.23 $2.49 $3.60
30-34 $3.05 $4.68 $3.44 $5.08
35-39 $4.18 $6.42 $4.57 $6.81
40-44 $5.35 $8.24 $5.75 $8.63
45-49 $7.02 $10.80 $7.41 $11.17
50-54 $9.72 $14.93 $10.11 $15.32
55-59 $12.48 $19.18 $12.85 $19.55
60-64 $16.06 $24.67 $16.45 $25.06
65-70 $18.00 $27.67 $18.39 $28.04

Underwritten by Colonial Life & Accident Insurance Company
Page 2 of 3 See page 3 for Important Notice