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2015 Benefits Guide
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VOLUNTARY LIFE/AD&D
EMPLOYEE CONTRIBUTION
(Rates are per month)
Age Band
Employee/Spouse
Rate per $1,000*
Under 30
$.048
30-34
$.056
35-39
$.071
40-44
$.100
45-49
$.150
50-54
$.230
55-59
$.402
60-64
$.572
65-69
$.918
70+
$1.735
AD&D
$0.017
Child Life
$0.240
Child AD&D
$0.510
*Spouse rates are based on the
employees age
ENROLLMENT WORKSHEET
Employee
$__________ ÷ 1,000 X $__________ = $___________
Amount of
Coverage
Unit Cost from
Rate Table
Employee
Monthly Cost
Spouse
$__________ ÷ 1,000 X $__________ = $___________
Amount of
Coverage
Unit Cost from
Rate Table
Spouse Monthly
Cost
Child(ren)
$__________ ÷ 1,000 X $__________ = $___________
Amount of
Unit Cost from Child(ren)