Page 24 - Stamford Residence & Rehabilitation - Benefit Guide 3-1-2021

Voluntary Life / AD&D Insurance:

Mutual of Omaha

Employee Life / AD&D Spouse Life / AD&D Child Life / AD&D

AGE Per Pay Period Cost Per Pay Period Cost Per Pay Period Cost for
per $10,000 of Face per $10,000 of Face Amount $10,000 Benefit on ALL
Amount Eligibility up to Age 75 Eligible Children to Age 26

Spouse Age Based
26 Pay Periods 26 Pay Periods 26 Pay Periods
on Employees Age
0-19 $0.51 $0.51 $.92 ALL CHILDREN

20-24 $0.51 $0.51 $.92 ALL CHILDREN

25 - 29 $0.51 $0.51 N/A

30 - 34 $0.55 $0.55 N/A

35 - 39 $0.60 $0.60 N/A

40 - 44 $0.88 $0.88 N/A

45 - 49 $1.43 $1.43 N/A

50 - 54 $2.22 $2.22 N/A

55 - 59 $3.42 $3.42 N/A

60 - 64 $5.26 $5.26 N/A

65 - 69 $9.32 $9.32 N/A

70 - 74 $16.57 $16.57 N/A

75 - 79 $27.23 N/A N/A

80 + $55.02 N/A N/A

Your rate will be calculated when you go through the online enrollment process.
Employees are responsible for paying the cost of voluntary life coverage through payroll deduction. Calculate the cost by dividing the amount of voluntary life insur-
ance by 100 and multiply by the appropriate rate above. Follow the example for a 35 year old below to determine your monthly cost. This example provides $100,000
of Basic Life and additional $100,000 AD&D for Total of $200,000. Rates are the same for smokers or non-smokers, males or females and employees or spouses.

Example amount
Divided by 1,000 Multiplied by rate of 35 year old Example Cost
of Insurance

$100,000 / 1000 = 100 X $0.06 $6.00

Example amount Multiplied by rate of 45 year
Divided by 1,000 Example Cost
of Insurance old
$100,000 / 1000 = 100 X $0.14 $14.31

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