Page 7 - Sample Life STD LTD Enrollment kit

[Employee] Life and
Age Range AD&D Group Rates for You
Premium Rate The estimated [monthly] premium for life and AD&D insurance is
[< 25] [.000000] determined by multiplying the desired amount of coverage [(in
[25 - 29] [.000000]
[30 - 34] [.000000] increments of $00,000)] by the [employee] age-range premium rate.
[35 - 39] [.000000]
[40 - 44] [.000000]
[45 - 49] [.000000] $ X = $
[50 - 54] [.000000] coverage amount premium rate [monthly] premium
[55 - 59] [.000000]
[60 - 64] [.000000] Note: Rates are subject to change and can vary over time.
[65 -69] [.000000]
[70 -74] [.000000]
[75 - 99] [.000000]

[Employee] | [Monthly] Premiums for Select Life and AD&D Insurance Coverage Amounts

[Employee] [$20,000] [$40,000] [$50,000] [$60,000] [$100,000] [$130,000] [$250,000] [$400,000]
Age Range
[< 25] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00]
[25 - 29] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00]
[30 - 34] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00]
[35 - 39] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00]
[40 - 44] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00]
[45 - 49] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00]
[50 - 54] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00]
[55 - 59] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00]
[60 - 64] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00]
[65 - 69] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00] [$0.00]

[Employee] [$13,000] [$26,000] [$32,500]
Age Range
[70-74] [$0.00] [$0.00] [$0.00]

[Employee] [$9,000] [$18,000] [$22,500]
Age Range
[75-99] [$0.00] [$0.00] [$0.00]

LFE-ENRO-BRC001-XX Life and AD&D Insurance Summary of Benefits