26-Pay Voluntary Critical Illness Premium Table

Reliance Standard Voluntary Plans Critical Illness Insurance Premium Table Plan Holder: Goshen Community Schools Scheduled Benefit: Each eligible employee may elect for himself and/or his eligible spouse an amount of insurance shown in the table below. Employee/Spouse Premiums: To find you and your spouse's premium -  Determine your age band: o Your age = your age at your last birthday. o Spouse age = your age at your last birthday. o When selecting an amount of insurance you must select at pre-age 70 benefit amount.  Select a benefit from: o Select an employee and spouse benefit from the table below.  Employee and spouse rates change as insured moves from one age bracket to the next, based on the age determination rules. Employee and Spouse Bi-Weekly Premiums Benefit Age Age Age Age Age Age Amount 0-29 30-39 40-49 50-59 60-69 70+ $10,000 $1.75 $3.14 $5.91 $10.62 $16.25 $31.94 $20,000 $3.51 $6.28 $11.82 $21.23 $32.49 $63.88 $30,000 $5.26 $9.42 $17.72 $31.85 $48.74 $95.82 Dependent Child(ren): Your dependent child(ren) is eligible for a benefit amount of 50% of your Critical Illness benefit election, limited to a maximum of $15,000 To calculate Dependent Child(ren) Benefit: Employee Benefit Amount x 50% = Dependent Child(ren) Benefit. No rounding needed. Dependent Child(ren) Rate is included in the Employee Premium. Please Note: One rate and benefit amount for all eligible children in family, regardless of number. Please read this important information - You may not have coverage as both an employee and as a dependent. - Employee must have coverage in order for spouse and dependent children to be covered. Please note, these rates are approximate and subject to change.