Page 17 - Benefits Guide 2022 EPO

Supplemental Life/AD&D Rate Calculations

Supplemental Life Coverage Monthly Rates
Employee per Spouse per
Age Band $10,000 $5,000 Child per $2,000
< 24 $.630 $.315 $.628
25-29 $.720 $.360
30-34 $.900 $.450
35-39 $1.270 $.635
40-44 $1.820 $.910
45-49 $2.900 $1.450 The premium paid for
50-54 $4.600 $2.300 child coverage is
55-59 $7.080 $3.540 based on the cost of
coverage for one
60-64 $11.050 $5.525 child, regardless of
65-69 $19.170 $9.585 how many children
70-74 $34.210 $17.105 you have.
75+ $67.050 $33.525

Supplemental AD&D Coverage Monthly Rates
Participant AD&D Cost Per Monthly Rate
Employee $10,000 $.409
Spouse $5,000 $.205
Child $2,000 $.080

Insurance Age: Your rate is based on your insurance age. To calculate your insurance age, subtract your
year of birth from the year your coverage becomes effective. (EX: 2022-1978 = 44; you will fall under the 40-
44 age band).

To Calculate Your Cost: Complete the section below using your coverage amount and rate (based on
your insurance age)

Supplemental Life Calculation
Coverage Amount Increment Rate Monthly Cost

Employee $ ¸ $10,000 X $ = $

Spouse $ ¸ $5,000 X $ = $

Child $ ¸ $2,000 X $ = $

Supplemental AD&D Calculation
Coverage Amount Increment Rate Monthly Cost

Employee $ ¸ $10,000 X $ = $

Spouse $ ¸ $5,000 X $ = $

Child $ ¸ $2,000 X $ = $

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