www.reliancematrix.com Reliance Matrix is branding name. Reliance Standard Life Insurance Company (Home Office Schaumburg, IL) is licensed in all states (except New York), the District of Columbia, Puerto Rico, the U.S. Virgin Islands and Guam. First Reliance Standard Life Insurance Company (Home Office New York, NY) is licensed in New York and Delaware. Standard Security Life Insurance Company of New York (Home Office New York, NY) is licensed in all states. Absence services are provided by Matrix Absence Management, Inc. Product features and availability may vary by state. Reliance Standard Plans Critical Illness Insurance Premium Table Plan Holder: Meyers Nave, A Professional Corporation Policy Number: VCI2000060712 SCHEDULED BENEFIT Each eligible employee may elect coverage for his/her self and eligible dependents, an amount of insurance shown in the table below. PREMIUMS To find your and your spouse's premium: • Determine your age band (your age as of your last birthday). • Select a benefit amount from the Benefit Amount column from the table below for you and your spouse. The rates for insurance you have elected will be found in the corresponding Age range column also below. Employee & Spouse Monthly Premiums: Dependent Child(ren) Your dependent child(ren) is eligible for a benefit amount of 50% of your Critical Illness benefit election. To calculate Dependent Child(ren) Benefit Employee Benefit Amount x 50% = Dependent Child(ren) Benefit. No rounding needed. Please read this important information You may not have coverage as both an employee and as a dependent. Employee must have coverage in order for spouse and dependent children to be covered, if applicable. Please Note: These rates are approximate and subject to change. Benefit Amount Age 0-29 Age 30-34 Age 35-39 Age 40-44 Age 45-49 Age 50-54 Age 55-59 Age 60-64 Age 65-69 Age 70-74 Age 75-79 Age 80-84 Age 85+ $5,000 $2.75 $5.15 $6.35 $6.70 $7.55 $10.20 $13.65 $19.50 $26.15 $35.60 $45.25 $56.40 $67.00 $10,000 $5.50 $10.30 $12.70 $13.40 $15.10 $20.40 $27.30 $39.00 $52.30 $71.20 $90.50 $112.80 $134.00 $15,000 $8.25 $15.45 $19.05 $20.10 $22.65 $30.60 $40.95 $58.50 $78.45 $106.80 $135.75 $169.20 $201.00 $20,000 $11.00 $20.60 $25.40 $26.80 $30.20 $40.80 $54.60 $78.00 $104.60 $142.40 $181.00 $225.60 $268.00 $25,000 $13.75 $25.75 $31.75 $33.50 $37.75 $51.00 $68.25 $97.50 $130.75 $178.00 $226.25 $282.00 $335.00 $30,000 $16.50 $30.90 $38.10 $40.20 $45.30 $61.20 $81.90 $117.00 $156.90 $213.60 $271.50 $338.40 $402.00