Page 9 - Sample Life STD LTD Enrollment kit

Spouse[/Domestic Partner] | [Monthly] Premiums for Select Life and AD&D Insurance Coverage Amounts

[Spouse][/
Domestic Partner] [$10,000] [$20,000] [$25,000] [$30,000] [$50,000] [$65,000] [$125,000] [$200,000]
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]

[Spouse][/
Domestic Partner] [$6,500] [$13,000] [$16,250]
Age Range
[70-74] [$0.00] [$0.00] [$0.00]

[Spouse][/
Domestic Partner] [$4,500] [$9,000] [$11,250]
Age Range
[75-99] [$0.00] [$0.00] [$0.00]

Coverage for Your Dependent Children

You can secure term life insurance for your dependent children when you choose coverage for yourself.
For children [age 14 days to 6 months], the maximum coverage amount is [$0,000]. [Newborn children
younger than the ages shown below are not eligible for coverage.]

Term Life Insurance | Dependent Children [age 6 months to 25 years]
Guaranteed coverage amount [Your choice of $0,000 or $00,000]

Term Life Insurance | Dependent Children [age 14 days to 6 months]

Guaranteed coverage amount [$0,000]

Dependent Children [Monthly] Premiums Group Rates for Your Dependent Children
for Life Insurance Coverage Amounts One affordable [monthly] premium covers all of your
dependent children [age 6 months to 25 years].
Coverage [Monthly]
Amount Premium
[$0,000] [$0.00]
[$00,000] [$0.00]

Note: You must be an active [Sample employee] to select coverage for a spouse[/domestic partner] and/
or dependent children. To be eligible for coverage, a spouse[/domestic partner] or dependent child
cannot be confined to a health care facility or unable to perform the typical activities of a healthy person
of the same age and gender. [Newborn children younger than the ages shown above are not eligible for
coverage.]

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