Page 14 - AssetHR Colonial Supplemental Health Offer

Deductions per year: 12 These rates were prepared on 10/20/2020 and are valid for 90 days.

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

Applicable to policy forms GCI6000-P, GCI6000-C,
Group Critical Illness (GCI6000) for MN R-GCI6000-CB, R-GCI6000-BB, R-GCI6000-HB,
R-GCI6000-INF, R-GCI6000-PD
l Plan 3 - Cancer, Without Wellbeing Assistance, First Diagnosis Building Benefit, Heart Benefits, Infectious Diseases Benefit

Non-Tobacco Rates
ISSUE AGE NAMED INSURED NAMED INSURED AND NAMED INSURED AND NAMED INSURED, SPOUSE
SPOUSE DEPENDENT CHILD(REN) AND DEPENDENT CHILD(REN)
$20,000 17-24 $10.02 $14.60 $10.02 $14.60
25-29 $13.43 $19.92 $13.43 $19.92
30-34 $16.85 $25.25 $16.85 $25.25
35-39 $21.55 $31.69 $21.55 $31.69
40-44 $26.05 $38.54 $26.05 $38.54
45-49 $33.98 $50.64 $33.98 $50.64
50-54 $45.51 $68.14 $45.51 $68.14
55-59 $55.40 $82.78 $55.40 $82.78
60-64 $75.30 $112.42 $75.30 $112.42
65-69 $93.10 $139.02 $93.10 $139.02
70-74 $93.10 $139.02 $93.10 $139.02
Tobacco Rates
ISSUE AGE NAMED INSURED NAMED INSURED AND NAMED INSURED AND NAMED INSURED, SPOUSE
SPOUSE DEPENDENT CHILD(REN) AND DEPENDENT CHILD(REN)
$20,000 17-24 $11.30 $16.92 $11.30 $16.92
25-29 $15.78 $23.14 $15.78 $23.14
30-34 $19.85 $29.35 $19.85 $29.35
35-39 $25.42 $38.10 $25.42 $38.10
40-44 $31.39 $46.66 $31.39 $46.66
45-49 $41.44 $61.93 $41.44 $61.93
50-54 $55.68 $83.00 $55.68 $83.00
55-59 $68.25 $102.14 $68.25 $102.14
60-64 $92.21 $137.88 $92.21 $137.88
65-69 $111.81 $167.08 $111.81 $167.08
70-74 $111.81 $167.08 $111.81 $167.08

Group Medical Bridge for MN Age-Banded Applicable to Policy Forms GMB1.0-P & GMB1.0-C
l Hospital Confinement: $2500, Health Screening: $50
ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE-PARENT FAMILY TWO-PARENT FAMILY
17-49 $19.56 $34.51 $27.01 $41.96
50-59 $24.67 $48.21 $32.12 $55.66
60-64 $33.81 $69.36 $41.26 $76.81

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