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Sugar Creek Realty
15
VOLUNTARY LIFE ENROLLMENT WORKSHEET
Employee
$__________
÷ 1,000 X ($__________
= $___________
(AD&D
+ .031)
Amount of
Coverage
Unit Cost from
Rate Table
Employee Monthly
Cost
Spouse
$__________
÷ 1,000 X ($__________
= $___________
(AD&D
+ .031)
Amount of
Coverage
Unit Cost from
Rate Table
Spouse Monthly
Cost
Child(ren)
$__________
÷ 1,000 X $__________
= $___________
Amount of
Coverage
Unit Cost from
Rate Table
Child(ren) Monthly
Cost
Employee & Spouse Monthly Rate/$1,000
Non-Tobacco User
Tobacco User
$0.069
$0.077
$0.115
$0.186
$0.287
$0.467
$0.734
$1.019
$1.880
$3.154
$0.128
$0.139
$0.208
$0.337
$0.519
$0.846
$1.329
$1.845
$3.406
$5.421
Under 29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70/Over
Age
Band