California
|
Basic AD&D
|
Policy Number 301401
|
|
Coverage Level
|
Volume
|
Rates
|
Number of Enrolled Employees
|
Premium
|
0-18
|
0
|
0.10
|
0
|
0
|
19-24
|
9,160,500
|
0.10
|
30
|
55.00
|
25-29
|
160,500
|
0.10
|
20
|
89.50
|
30-34
|
60,500
|
0.10
|
10
|
52.00
|
35-39
|
260,500
|
0.10
|
15
|
51.50
|
40-44
|
1,160,500
|
0.10
|
4
|
450.00
|
45-49
|
1,160,500
|
0.10
|
2
|
450.00
|
50-54
|
1,160,500
|
0.10
|
2
|
450.00
|
55-59
|
0
|
0.10
|
0
|
0
|
60-64
|
1,160,500
|
0.10
|
1
|
450.00
|
65 and over
|
0
|
0.10
|
0
|
0
|
Sub Total
|
$10,802,500
|
|
175
|
$698.00
|
Adjustments
|
0
|
|
|
0
|
Basic AD&D Total
|
$10,802,500
|
|
175
|
$698.00
|
|
Basic Life
|
Policy Number 123401
|
|
Coverage Level
|
Volume
|
Rates
|
Number of Enrolled Employees
|
Premium
|
1 x Salary
|
6,794,400
|
100.00
|
25
|
2,500.00
|
Sub Total
|
$6,794,400
|
|
100
|
$20,375.00
|
Adjustments
|
0
|
|
|
0
|
Basic Life Total
|
$6,794,400
|
|
100
|
$20,375.00
|
|
|
Coverage Level
|
Rates
|
Number of Enrolled Employees
|
Premium
|
Employee
|
100.00
|
25
|
2,500.00
|
Employee + Spouse
|
200.00
|
10
|
2,000.00
|
Employee + Child(ren)
|
175.00
|
20
|
3,500.00
|
Family
|
270.00
|
45
|
12,375.00
|
Sub Total
|
100
|
$20,375.00
|
Adjustments
|
0
|
0
|
HMO Total
|
100
|
$20,375.00
|
|
Long Term Disability
|
Policy Number 33401
|
|
Coverage Level
|
Volume
|
Rates
|
Number of Enrolled Employees
|
Premium
|
50% of monthly salary
|
$2,500.00
|
0.12
|
1
|
$2,500.00
|
Sub Total
|
$2,500.00
|
|
1
|
$2,500.00
|
Adjustments
|
0
|
|
|
0
|
Long Term Disability Total
|
$2,500.00
|
|
1
|
$2,500.00
|
|
|
Coverage Level
|
Rates
|
Number of Enrolled Employees
|
Premium
|
Employee
|
100.00
|
25
|
2,500.00
|
Employee + Spouse
|
200.00
|
10
|
2,000.00
|
Employee + Child(ren)
|
175.00
|
20
|
3,500.00
|
Family
|
270.00
|
45
|
12,375.00
|
Sub Total
|
100
|
$20,375.00
|
Adjustments
|
0
|
0
|
PPO Total
|
100
|
$20,375.00
|
California Total
|
100
|
$1,150.00
|
|