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00 <br /> Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021 GM <br /> Additional Life and AD&D Insurance (Continued) <br /> Employee/Spouse Rates Additional Dependent Child(ren)Life Coverage Amount <br /> If employee elects additional life with AD&D insurance,the monthly premium • Employee may elect Additional Dependent Life and AD&D insurance <br /> rate for this plan is indicated in the table below.Premiums for coverage will be for eligible dependent child(ren). <br /> deducted directly from employee's paycheck. • Employee may elect one(1)of the following options for dependent <br /> life coverage: <br /> To calculate the premium: > $2,000 <br /> 1.Amount elected:Write this amount on the > $5,000 <br /> additional life requested amount line on line 1: > $10,000 <br /> employee Enrollment and Change Form. • AD&D insurance from The Standard Insurance Company is included <br /> Line 2: in the above mentioned plans. <br /> 2.Line 1 divided by$1,000 • Monthly premium rates for Additional Dependent Child(ren) Life <br /> Line 3: insurance coverage are listed in the table to the below. <br /> 3.Select rate from the rate table <br /> Line 4: Please Note: Applications for all plans will be subject to Medical <br /> 4.Line 2 multiplied by Line 3=Monthly cost. Underwriting approval.(Except new hires under the Guarantee Issue.) <br /> Additional Life and AD&D insurance Rate Table Additional Dependent Child(ren)Life and AD&D Insurance <br /> Monthly Premium Monthly Premium <br /> Age Bracket Employee/Spouse Benefit Amount Rate Per Benefit Amount <br /> (Based on Employee Age) (Rate Per$1,000ofBenefit) <br /> .- ._. . $2,000 $0.40 <br /> <30 $0.140 <br /> 30-34 $0.150 0,000 $2.00 <br /> $5,000 $1.00 <br /> —_ - -- -- <br /> 1 <br /> •Y- _ 35-39J $0.185 <br /> F--- 40-44 J $0.250 The Standard I Customer Service:(800)247-6888 I www.standard.com <br /> • 45-49 $0.405 <br /> 50-54 $0.590 <br /> 55-59 $0.965 <br /> 60-64 J $1.090 i <br /> 65-69 $1.980 I <br /> 70-75 $3.220 i <br /> - i <br /> 75+ $10.50 <br /> • <br /> 127 <br /> 18 <br /> 02016,Gehring Group,Inc.,AD Rights Reserved <br />