Page 22 - Mom's Flipbook

PLAN 1 PLAN 2
BI-WEEKLY ISSUE AGE BI-WEEKLY ISSUE AGE
PREMIUMS PREMIUMS
AGE EE, EE+CH EE+SP, F EE, EE+CH EE+SP, F EE, EE+CH EE+SP, F EE, EE+CH EE+SP, F
Non-Tobacco Tobacco Non-Tobacco Tobacco
18-29 $3.66 $6.44 $4.34 $7.46 $5.38 $9.04 $6.76 $11.08
30-39 $5.86 $9.82 $7.62 $12.44 $9.66 $15.50 $13.18 $20.76
40-49 $10.04 $16.20 $14.40 $22.74 $17.82 $27.84 $26.54 $40.94
50-59 $16.54 $26.10 $24.72 $38.36 $30.54 $47.08 $46.88 $71.58
60-64 $22.14 $34.60 $33.30 $51.32 $41.54 $63.68 $63.82 $97.12
65+ $34.60 $53.44 $51.74 $79.16 $66.08 $100.66 $100.38 $152.10
EE = Employee; EE + SP = Employee + Spouse; EE + CH = Employee + Child(ren); F = Family

FOR HOME OFFICE USE ONLY - GVCIP4
Opt 1 - No Pre-Ex; 1.0U Base; CCILB: RCIB; RCCIB; SCI W/O; SCR; CER; SCIR365; 4U FWR;
Opt 2 - No Pre-Ex; 2.0U Base; CCILB: RCIB; RCCIB; SCI W/O; SCR; CER; SCIR365; 4U FWR;

ABQ V 06.15.2021 Proposal Creation Date: 8/4/2021

For use in enrollments sitused in: VA. This rate insert is part of the approved brochure for Mom's Organic Market and is not to be used on its
own.
This material is valid as long as information remains current, but in no event later than August 4, 2024. Allstate Benefits is the
marketing name used by American Heritage Life Insurance Company (Home Office, Jacksonville, FL), a subsidiary of The Allstate
Corporation. ©2021 Allstate Insurance Company. www.allstate.com or allstatebenefits.com.

GVCIP4 - Insert - 29167-No Pre-Ex