Dependent Child(ren) 18 Payment Periods Premiums: Benefit Amount Premium $2,000 $0.35 $4,000 $0.69 $6,000 $1.04 $8,000 $1.39 $10,000 $1.73 (One rate and benefit amount for all eligible children in family, regardless of number) PREMIUM CALCULATION (Add your elections here): Employee Premium Spouse Premium Dependent Child(ren) Premium Total Premium (Rates are calculated as of coverage effective date and are based on insured's age in relation to Plan anniversary date. Billed rates may be higher if, at application, the person is at the highest age in an age band). Please read this important information:  You may not have coverage as both an employee and as a dependent.  Only one insured spouse may cover the eligible dependent children. Rates are subject to change. Page 3 of 3