Page 24 - Benefit Book - Kilian - Colonial Life

Deductions per year: 12 These rates were prepared on 11/3/2020 and are valid for 90 days.

Individual Dental PPO(IDN8000) for MN Applicable to policy form Individual Dental PPO(IDN8000)

l with Rollover Benefit

Zip Codes: 550, 551, 553, 554, 560, 563, 564
COVERAGE LEVEL ISSUE AGE INDIVIDUAL INDIVIDUAL AND INDIVIDUAL AND INDIVIDUAL AND
SPOUSE CHILDREN FAMILY
Plan 4 - 100/80/50, 17-74 $37.42 $71.08 $89.54 $132.62
$2,000 MAC

Disability 1000 for MN A Risk Class Applicable to policy form DIS1000
l Off-Job Accident, Off-Job Sickness with Health Screening Rider
6 Month Benefit Period
ELIMINATION PERIOD ISSUE AGE $1,000* $1,500* $2,000* $2,500*
0 days Accident / 7 days Sickness 17-49 $26.86 $39.81 $52.76 $65.71
50-69 $34.86 $51.81 $68.76 $85.71
0 days Accident / 14 days Sickness 17-49 $21.96 $32.46 $42.96 $53.46
50-69 $28.56 $42.36 $56.16 $69.96
*monthly benefit amount

Group Accident for MN Applicable to policy forms GACC1.0-P & GACC1.0-C

l On/Off-Job Accident Coverage, Health Screening Benefit ($100)
Plan 3
ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY
17-99 $22.26 $35.37 $36.38 $49.49

Individual Medical Bridge for MN Applicable to policy form Individual Medical Bridge
l $1500 Hospital Confinement Benefit.

ISSUE AGE EMPLOYEE EMPLOYEE AND SPOUSE EMPLOYEE AND DEPENDENT EMPLOYEE, SPOUSE AND
CHILDREN DEPENDENT CHILDREN
17-49 $14.35 $27.45 $19.55 $32.65
50-59 $20.25 $38.30 $25.45 $43.50
60-64 $27.70 $52.55 $32.90 $57.75
65-75 $36.80 $70.10 $42.00 $75.30

Cancer Assist for MN Applicable to policy form CanAssist
l with Specified Disease Benefit, Progressive Payment Benefit, $100 Health Screening Benefit
$10,000 Initial Diagnosis Benefit
COVERAGE LEVEL ISSUE AGE NAMED INSURED EMPLOYEE AND SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY
Level 3 17-75 $47.00 $81.40 $48.45 $82.85

Underwritten by Colonial Life & Accident Insurance Company
Page 1 of 2 See page 2 for Important Notice