Employee’s Bi-Weekly Cost of Coverage: Benefit Amount: $10,000 Age Employee
Employee + Spouse
Employee + Children
Employee + Family
<25
$1.06 $1.20 $1.62 $2.22 $2.88 $4.08 $6.01 $8.62
$1.73 $1.95 $2.59 $3.60 $4.66 $6.66 $9.60 $13.50 $17.25 $21.08 $29.33 $39.82 $49.62 $68.03 $68.03 $68.03 $3.45 $3.90 $5.19 $7.20 $9.31 $13.31 $19.19 $27.00 $34.50 $42.16 $58.65 $79.64 $99.24 $136.05 $136.05 $136.05
$2.01 $2.16 $2.58 $3.17 $3.83 $5.03 $6.96 $9.57
$2.67 $2.90 $3.54 $4.55 $5.61 $7.61 $10.55 $14.45 $18.20 $22.02 $30.27 $40.77 $50.57 $68.98 $68.98 $68.98 $5.34 $5.80 $7.08 $9.09 $11.22 $15.21 $21.09 $28.90 $36.41 $44.05 $60.54 $81.54 $101.14 $137.95 $137.95 $137.95
25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74 75 to 79 80 to 84 85 to 89 90 to 94
$11.12 $13.49 $18.87 $26.71 $34.38 $43.05 $43.05 $43.05 $2.11 $2.41 $3.25 $4.44 $5.76 $8.16 $12.03 $17.24 $22.25 $26.98 $37.74 $53.42 $68.76 $86.10 $86.10 $86.10
$12.07 $14.44 $19.81 $27.66 $35.33 $44.00 $44.00 $44.00 $4.02 $4.31 $5.15 $6.34 $7.66 $10.06 $13.92 $19.14 $24.15 $28.88 $39.63 $55.32 $70.66 $88.01 $88.01 $88.01
95+
Benefit Amount: $20,000 Age Employee
Employee + Spouse
Employee + Children
Employee + Family
<25
25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74 75 to 79 80 to 84 85 to 89 90 to 94
95+
Costs are subject to change. Actual per pay period premiums may differ slightly due to rounding. The policy's rate structure is based on attained age, which means the premium can increase due to the increase in your age.
Important Policy Provisions and Definitions: Covered Person: An eligible person who is enrolled for coverage under the Policy. Covered Loss: A loss that is specified in the Policy in the Schedule of Benefits section and suffered by the Covered Person within the applicable time period described in the Policy. When your coverage begins: Coverage begins on the later of the program’s effective date, the date you become eligible, the first of the month following the date your completed enrollment form is received, or if evidence of insurability is required, the first of the month after we have approved you (or your dependent) for coverage in writing, unless otherwise agreed upon by Cigna. Your coverage will not begin unless you are actively at work on the effective date. Coverage for all other Covered Persons will not begin on the effective date if the covered person is confined to a hospital, facility or at home, disabled or receiving disability benefits or unable to perform activities of daily living. When your coverage ends: Coverage ends on the earliest of the date you and your dependents are no longer eligible, the date the group policy is no longer in force, or the date for the last period for which required premiums are paid. For your dependent, coverage also ends when your coverage ends, when their premiums are not paid or when they are no longer eligible. (Under certain circumstances, your coverage may be continued. Be sure to read the provisions in your Certificate about when coverage may continue.) 30 Day Right To Examine Certificate: If a Covered Person is not satisfied with the Certificate of Insurance for any reason, it may be returned to us within 30 days after receipt. We will return any premium that has been paid and the Certificate will be void as if it had never been issued. Benefit Reductions, Common Exclusions and Limitations: Exclusions: In addition to any benefit-specific exclusions, benefits will not be paid for any Covered Loss that is caused directly or indirectly, in whole or in part by any of the following:• intentionally self-inflicted injury, suicide or any attempt
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