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2015-2016 Benefits Guide
16
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
Coverage
Unit Cost from
Rate Table
Child(ren)
Monthly Cost
Employee Monthly Cost
Age Band
Employee/Spouse
Rate per $1,000
Under 30
$0.054
30-34
$0.072
35-39
$0..081
40-44
$0.118
45-49
$0.185
50-54
$0.286
55-59
$0.435
60-64
$.597
65-69
$1.143
70+
$1.854
AD&D
EE & SP $0.025
Child $.051