18-Pay Premium Table Voluntary Life Insurance

Reliance Standard Plans Supplemental and Dependent Life Insurance Premium Table Plan Holder: Goshen Community Schools Scheduled Benefit: Each eligible employee may elect for himself/herself and/or his/her eligible spouse an amount of insurance shown in the table below. For employees age 65 and older: Benefit amounts are reduced according to the age-based reduction chart shown in the Supplemental Life brochure. Employee/Spouse Premiums: To find you and your spouse's premium:  Determine your age band: Your age = your age at your last birthday.  Select a benefit amount (employees age 65 and older: see above comment).  Spouse premium: Repeat the steps above for your spouse at your age at your last birthday.  Employee and spouse rates change as insured moves from one age bracket to the next. Employee 18 Payment Periods Premiums Benefit Age Age Age Age Age Age Age Age Age Age Age Age Amount 18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+ $10,000 $0.40 $0.40 $0.53 $0.60 $0.67 $1.00 $1.53 $2.87 $4.40 $8.47 $13.73 $13.73 $20,000 $0.80 $0.80 $1.07 $1.20 $1.33 $2.00 $3.07 $5.73 $8.80 $16.93 $27.47 $27.47 $30,000 $1.20 $1.20 $1.60 $1.80 $2.00 $3.00 $4.60 $8.60 $13.20 $25.40 $41.20 $41.20 $40,000 $1.60 $1.60 $2.13 $2.40 $2.67 $4.00 $6.13 $11.47 $17.60 $33.87 $54.93 $54.93 $50,000 $2.00 $2.00 $2.67 $3.00 $3.33 $5.00 $7.67 $14.33 $22.00 $42.33 $68.67 $68.67 $60,000 $2.40 $2.40 $3.20 $3.60 $4.00 $6.00 $9.20 $17.20 $26.40 $50.80 $82.40 $82.40 $70,000 $2.80 $2.80 $3.73 $4.20 $4.67 $7.00 $10.73 $20.07 $30.80 $59.27 $96.13 $96.13 $80,000 $3.20 $3.20 $4.27 $4.80 $5.33 $8.00 $12.27 $22.93 $35.20 $67.73 $109.87 $109.87 $90,000 $3.60 $3.60 $4.80 $5.40 $6.00 $9.00 $13.80 $25.80 $39.60 $76.20 $123.60 $123.60 $100,000 $4.00 $4.00 $5.33 $6.00 $6.67 $10.00 $15.33 $28.67 $44.00 $84.67 $137.33 $137.33 $110,000 $4.40 $4.40 $5.87 $6.60 $7.33 $11.00 $16.87 $31.53 $48.40 $93.13 $151.07 $151.07 $120,000 $4.80 $4.80 $6.40 $7.20 $8.00 $12.00 $18.40 $34.40 $52.80 $101.60 $164.80 $164.80 $130,000 $5.20 $5.20 $6.93 $7.80 $8.67 $13.00 $19.93 $37.27 $57.20 $110.07 $178.53 $178.53 $140,000 $5.60 $5.60 $7.47 $8.40 $9.33 $14.00 $21.47 $40.13 $61.60 $118.53 $192.27 $192.27 $150,000 $6.00 $6.00 $8.00 $9.00 $10.00 $15.00 $23.00 $43.00 $66.00 $127.00 $206.00 $206.00 $160,000 $6.40 $6.40 $8.53 $9.60 $10.67 $16.00 $24.53 $45.87 $70.40 $135.47 $219.73 $219.73 $170,000 $6.80 $6.80 $9.07 $10.20 $11.33 $17.00 $26.07 $48.73 $74.80 $143.93 $233.47 $233.47 $180,000 $7.20 $7.20 $9.60 $10.80 $12.00 $18.00 $27.60 $51.60 $79.20 $152.40 $247.20 $247.20 $190,000 $7.60 $7.60 $10.13 $11.40 $12.67 $19.00 $29.13 $54.47 $83.60 $160.87 $260.93 $260.93 $200,000 $8.00 $8.00 $10.67 $12.00 $13.33 $20.00 $30.67 $57.33 $88.00 $169.33 $274.67 $274.67 $210,000 $8.40 $8.40 $11.20 $12.60 $14.00 $21.00 $32.20 $60.20 $92.40 $177.80 $288.40 $288.40 $220,000 $8.80 $8.80 $11.73 $13.20 $14.67 $22.00 $33.73 $63.07 $96.80 $186.27 $302.13 $302.13 $230,000 $9.20 $9.20 $12.27 $13.80 $15.33 $23.00 $35.27 $65.93 $101.20 $194.73 $315.87 $315.87 $240,000 $9.60 $9.60 $12.80 $14.40 $16.00 $24.00 $36.80 $68.80 $105.60 $203.20 $329.60 $329.60 $250,000 $10.00 $10.00 $13.33 $15.00 $16.67 $25.00 $38.33 $71.67 $110.00 $211.67 $343.33 $343.33 $260,000 $10.40 $10.40 $13.87 $15.60 $17.33 $26.00 $39.87 $74.53 $114.40 $220.13 $357.07 $357.07 $270,000 $10.80 $10.80 $14.40 $16.20 $18.00 $27.00 $41.40 $77.40 $118.80 $228.60 $370.80 $370.80 $280,000 $11.20 $11.20 $14.93 $16.80 $18.67 $28.00 $42.93 $80.27 $123.20 $237.07 $384.53 $384.53 $290,000 $11.60 $11.60 $15.47 $17.40 $19.33 $29.00 $44.47 $83.13 $127.60 $245.53 $398.27 $398.27 $300,000 $12.00 $12.00 $16.00 $18.00 $20.00 $30.00 $46.00 $86.00 $132.00 $254.00 $412.00 $412.00 $310,000 $12.40 $12.40 $16.53 $18.60 $20.67 $31.00 $47.53 $88.87 $136.40 $262.47 $425.73 $425.73 $320,000 $12.80 $12.80 $17.07 $19.20 $21.33 $32.00 $49.07 $91.73 $140.80 $270.93 $439.47 $439.47 $330,000 $13.20 $13.20 $17.60 $19.80 $22.00 $33.00 $50.60 $94.60 $145.20 $279.40 $453.20 $453.20 $340,000 $13.60 $13.60 $18.13 $20.40 $22.67 $34.00 $52.13 $97.47 $149.60 $287.87 $466.93 $466.93 $350,000 $14.00 $14.00 $18.67 $21.00 $23.33 $35.00 $53.67 $100.33 $154.00 $296.33 $480.67 $480.67 $360,000 $14.40 $14.40 $19.20 $21.60 $24.00 $36.00 $55.20 $103.20 $158.40 $304.80 $494.40 $494.40 $370,000 $14.80 $14.80 $19.73 $22.20 $24.67 $37.00 $56.73 $106.07 $162.80 $313.27 $508.13 $508.13 $380,000 $15.20 $15.20 $20.27 $22.80 $25.33 $38.00 $58.27 $108.93 $167.20 $321.73 $521.87 $521.87 $390,000 $15.60 $15.60 $20.80 $23.40 $26.00 $39.00 $59.80 $111.80 $171.60 $330.20 $535.60 $535.60 Page 1 of 3