Coverage Effective January 1, 2024

Term to Age 100 Life Insurance

Traditional Term Life Insurance will have rate increases as you age, this Term Life Insurance will never have a rate increase to age 100. Lock in this bi-weekly premium as soon as you can when it’s most affordable!

The life insurance benefit provides cash for final expenses in the event of your death, the financial protection for those you love most. Dealing with an unexpected death is difficult enough – you don’t want to leave behind overwhelming financial obligations as well. With a Term Life Insurance 100 policy from Allstate Benefits, your family can still realize all the goals and dreams you shared together.

$25,000

$50,000

$75,000

$100,000 *Requires Evidence of Good Health*

$10,000 (Non-Working Spouse) *If Specific Age Range

$25,000 (Working Spouse)

$50,000 (Working Spouse) *Requires Evidence of Good Health*

$75,000 (Working Spouse) *Requires Evidence of Good Health*

$100,000 (Working Spouse) *Requires Evidence of Good Health*

$10,000 (Under Age 26)

$20,000 (Under Age 26)

Traditional Term Life Insurance will have rate increases as you age, this Term Life Insurance will never have a rate increase to age 100. Lock in this bi-weekly premium as soon as you can when it’s most affordable!

See Brochure & Rates Below.

Term to Age 100 – Biweekly Brochure and Rates

Altra Federal Credit Union Term to 100 Life Insurance Form

Name(Required)

First Last

Social Security Number(Required)

Date of Birth(Required)

Address(Required)

Street Address City State ZIP Code

Email(Required)

Are You a Tobacco User(Required)

How Old Will You be on January 1,2024(Required)

Age 18: Employee Biweekly Premium(Required)

Biweekly Premium for Ages 18

$25,000 | $5.00

$50,000 | $10.00

$75,000 | $15.00

$100,000 | $20.00 *Requires evidence of good health

N.A. | Waive Coverage

Age 19-25: Employee Biweekly Premium(Required)

Biweekly Premium for Ages 19-25

$50,000 | $6.94

$75,000 | $10.40

$100,000 | $13.86 *Requires evidence of good health

N.A. | Waive Coverage

Age 26: Employee Biweekly Premium(Required)

Biweekly Premium for Age 26

$50,000 | $7.04

$75,000 | $10.56

$100,000 | $14.08 *Requires evidence of good health

N.A. | Waive Coverage

Age 27: Employee Biweekly Premium(Required)

Biweekly Premium for Age 27

$50,000 | $7.16

$75,000 | $10.74

$100,000 | $14.32 *Requires evidence of good health

N.A. | Waive Coverage

Age 28: Employee Biweekly Premium(Required)

Biweekly Premium for Age 28

$50,000 | $7.28

$75,000 | $10.92

$100,000 | $14.54 *Requires evidence of good health

N.A. | Waive Coverage

Age 29: Employee Biweekly Premium(Required)

Biweekly Premium for Age 29

$50,000 | $7.40

$75,000 | $11.08

$100,000 | $14.78 *Requires evidence of good health

N.A. | Waive Coverage

Age 30: Employee Biweekly Premium(Required)

Biweekly Premium for Age 30

$50,000 | $7.50

$75,000 | $11.26

$100,000 | $15.00 *Requires evidence of good health

N.A. | Waive Coverage

Age 31: Employee Biweekly Premium(Required)

Biweekly Premium for Age 31

$50,000 | $7.90

$75,000 | $11.84

$100,000 | $15.78 *Requires evidence of good health

N.A. | Waive Coverage

Age 32: Employee Biweekly Premium(Required)

Biweekly Premium for Age 32

$25,000 | $4.14

$50,000 | $8.28

$75,000 | $12.42

$100,000 | $16.54 *Requires evidence of good health

N.A. | Waive Coverage

Age 33: Employee Biweekly Premium(Required)

Biweekly Premium for Age 33

$25,000 | $4.34

$50,000 | $8.66

$75,000 | $13.00

$100,000 | $17.32 *Requires evidence of good health

N.A. | Waive Coverage

Age 34: Employee Biweekly Premium(Required)

Biweekly Premium for Age 34

$25,000 | $4.52

$50,000 | $9.04

$75,000 | $13.56

$100,000 | $18.08 *Requires evidence of good health

N.A. | Waive Coverage

Age 35: Employee Biweekly Premium(Required)

Biweekly Premium for Age 35

$25,000 | $4.72

$50,000 | $9.44

$75,000 | $14.14

$100,000 | $18.86 *Requires evidence of good health

N.A. | Waive Coverage

Age 36: Employee Biweekly Premium(Required)

Biweekly Premium for Age 36

$25,000 | $4.92

$50,000 | $9.84

$75,000 | $14.74

$100,000 | $19.66 *Requires evidence of good health

N.A. | Waive Coverage

Age 37: Employee Biweekly Premium(Required)

Biweekly Premium for Age 37

$25,000 | $5.34

$50,000 | $10.68

$75,000 | $16.02

$100,000 | $21.36 *Requires evidence of good health

N.A. | Waive Coverage

Age 38: Employee Biweekly Premium(Required)

Biweekly Premium for Age 38

$25,000 | $5.74

$50,000 | $11.50

$75,000 | $17.22

$100,000 | $22.96 *Requires evidence of good health

N.A. | Waive Coverage

Age 39: Employee Biweekly Premium(Required)

Biweekly Premium for Age 39

$25,000 | $6.16

$50,000 | $12.30

$75,000 | $18.44

$100,000 | $24.58 *Requires evidence of good health

N.A. | Waive Coverage

Age 40: Employee Biweekly Premium(Required)

Biweekly Premium for Age 40

$25,000 | $6.56

$50,000 | $13.10

$75,000 | $19.66

$100,000 | $26.20 *Requires evidence of good health

N.A. | Waive Coverage

Age 41: Employee Biweekly Premium(Required)

Biweekly Premium for Age 41

$25,000 | $7.18

$50,000 | $14.38

$75,000 | $21.56

$100,000 | $28.74 *Requires evidence of good health

N.A. | Waive Coverage

Age 42: Employee Biweekly Premium(Required)

Biweekly Premium for Age 42

$25,000 | $7.82

$50,000 | $15.62

$75,000 | $23.44

$100,000 | $31.24 *Requires evidence of good health

N.A. | Waive Coverage

Age 43: Employee Biweekly Premium(Required)

Biweekly Premium for Age 43

$25,000 | $8.44

$50,000 | $16.88

$75,000 | $25.30

$100,000 | $33.74 *Requires evidence of good health

N.A. | Waive Coverage

Age 44: Employee Biweekly Premium(Required)

Biweekly Premium for Age 44

$25,000 | $9.08

$50,000 | $18.14

$75,000 | $27.22

$100,000 | $36.28 *Requires evidence of good health

N.A. | Waive Coverage

Age 45: Employee Biweekly Premium(Required)

Biweekly Premium for Age 45

$25,000 | $9.70

$50,000 | $19.40

$75,000 | $29.08

$100,000 | $38.78 *Requires evidence of good health

N.A. | Waive Coverage

Age 46: Employee Biweekly Premium(Required)

Biweekly Premium for Age 46

$25,000 | $10.48

$50,000 | $20.98

$75,000 | $31.46

$100,000 | $41.92 *Requires evidence of good health

N.A. | Waive Coverage

Age 47: Employee Biweekly Premium(Required)

Biweekly Premium for Age 47

$25,000 | $11.26

$50,000 | $22.52

$75,000 | $33.78

$100,000 | $45.04 *Requires evidence of good health

N.A. | Waive Coverage

Age 48: Employee Biweekly Premium(Required)

Biweekly Premium for Age 48

$25,000 | $12.04

$50,000 | $24.06

$75,000 | $36.10

$100,000 | $48.12 *Requires evidence of good health

N.A. | Waive Coverage

Age 49: Employee Biweekly Premium(Required)

Biweekly Premium for Age 49

$25,000 | $12.80

$50,000 | $25.60

$75,000 | $38.40

$100,000 | $51.20 *Requires evidence of good health

N.A. | Waive Coverage

Age 50: Employee Biweekly Premium(Required)

Biweekly Premium for Age 50

$25,000 | $13.58

$50,000 | $27.14

$75,000 | $40.72

$100,000 | $54.28 *Requires evidence of good health

N.A. | Waive Coverage

Age 51: Employee Biweekly Premium(Required)

Biweekly Premium for Age 51

$25,000 | $14.98

$50,000 | $29.96

$75,000 | $44.92

$100,000 | $59.90 *Requires evidence of good health

N.A. | Waive Coverage

Age 52: Employee Biweekly Premium(Required)

Biweekly Premium for Age 52

$25,000 | $16.40

$50,000 | $32.78

$75,000 | $49.16

$100,000 | $65.54 *Requires evidence of good health

N.A. | Waive Coverage

Age 53: Employee Biweekly Premium(Required)

Biweekly Premium for Age 53

$25,000 | $17.80

$50,000 | $35.58

$75,000 | $53.38

$100,000 | $71.16 *Requires evidence of good health

N.A. | Waive Coverage

Age 54: Employee Biweekly Premium(Required)

Biweekly Premium for Age 54

$25,000 | $19.20

$50,000 | $38.40

$75,000 | $57.58

$100,000 | $76.78 *Requires evidence of good health

N.A. | Waive Coverage

Age 55: Employee Biweekly Premium(Required)

Biweekly Premium for Age 55

$25,000 | $21.64

$50,000 | $43.28

$75,000 | $64.92

$100,000 | $86.54 *Requires evidence of good health

N.A. | Waive Coverage

Age 56: Employee Biweekly Premium(Required)

Biweekly Premium for Age 56

$25,000 | $23.60

$50,000 | $47.18

$75,000 | $70.76

$100,000 | $94.36 *Requires evidence of good health

N.A. | Waive Coverage

Age 57: Employee Biweekly Premium(Required)

Biweekly Premium for Age 57

$25,000 | $25.54

$50,000 | $51.08

$75,000 | $76.62

$100,000 | $102.16 *Requires evidence of good health

N.A. | Waive Coverage

Age 58: Employee Semimonthly Premium(Required)

Biweekly Premium for Age 58

$25,000 | $27.50

$50,000 | $55.00

$75,000 | $82.48

$100,000 | $109.96 *Requires evidence of good health

N.A. | Waive Coverage

Age 59: Employee Biweekly Premium(Required)

Biweekly Premium for Age 59

$25,000 | $29.44

$50,000 | $58.90

$75,000 | $88.34

$100,000 | $117.78 *Requires evidence of good health

N.A. | Waive Coverage

Age 60: Employee Biweekly Premium(Required)

Biweekly Premium for Age 60

$25,000 | $31.38

$50,000 | $62.76

$75,000 | $94.14

$100,000 | $125.50 *Requires evidence of good health

N.A. | Waive Coverage

Age 61: Employee Biweekly Premium(Required)

Biweekly Premium for Age 61

$25,000 | $34.40

$50,000 | $68.80

$75,000 | $103.18

$100,000 | $137.58 *Requires evidence of good health

N.A. | Waive Coverage

Age 62: Employee Biweekly Premium(Required)

Biweekly Premium for Age 62

$25,000 | $37.42

$50,000 | $74.84

$75,000 | $112.24

$100,000 | $149.66 *Requires evidence of good health

N.A. | Waive Coverage

Age 63: Employee Biweekly Premium(Required)

Biweekly Premium for Age 63

$25,000 | $40.46

$50,000 | $80.90

$75,000 | $121.34

$100,000 | $161.78 *Requires evidence of good health

N.A. | Waive Coverage

Age 64: Employee Biweekly Premium(Required)

Biweekly Premium for Age 64

$25,000 | $43.48

$50,000 | $86.92

$75,000 | $130.40

$100,000 | $173.86 *Requires evidence of good health

N.A. | Waive Coverage

Age 65: Employee Biweekly Premium(Required)

Biweekly Premium for Age 65

$25,000 | $46.48

$50,000 | $92.98

$75,000 | $139.46

$100,000 | $185.92 *Requires evidence of good health

N.A. | Waive Coverage

Age 66: Employee Biweekly Premium(Required)

Biweekly Premium for Age 66

$25,000 | $51.14

$50,000 | $102.28

$75,000 | $153.42

$100,000 | $204.54 *Requires evidence of good health

N.A. | Waive Coverage

Age 67: Employee Biweekly Premium(Required)

Semimonthly Premium for Age 67

$25,000 | $55.78

$50,000 | $111.56

$75,000 | $167.34

$100,000 | $223.12 *Requires evidence of good health

N.A. | Waive Coverage

Age 68: Employee Biweekly Premium(Required)

Biweekly Premium for Age 68

$25,000 | $60.44

$50,000 | $120.88

$75,000 | $181.30

$100,000 | $241.74 *Requires evidence of good health

N.A. | Waive Coverage

Age 69: Employee Biweekly Premium(Required)

Biweekly Premium for Age 69

$25,000 | $65.08

$50,000 | $130.16

$75,000 | $195.24

$100,000 | $260.32 *Requires evidence of good health

N.A. | Waive Coverage

Age 70: Employee Biweekly Premium(Required)

Biweekly Premium for Age 70

$25,000 | $69.72

$50,000 | $139.46

$75,000 | $209.18

$100,000 | $278.90 *Requires evidence of good health

N.A. | Waive Coverage

Age 71: Employee Biweekly Premium(Required)

Biweekly Premium for Age 71

$25,000 | $82.06

$50,000 | $164.12

$75,000 | $246.18

$100,000 | $328.24 *Requires evidence of good health

N.A. | Waive Coverage

Age 72: Employee Biweekly Premium(Required)

Biweekly Premium for Age 72

$25,000 | $85.18

$50,000 | $170.34

$75,000 | $255.50

$100,000 | $340.66 *Requires evidence of good health

N.A. | Waive Coverage

Age 73: Employee Biweekly Premium(Required)

Biweekly Premium for Age 73

$25,000 | $88.52

$50,000 | $177.04

$75,000 | $265.56

$100,000 | $354.08 *Requires evidence of good health

N.A. | Waive Coverage

Age 74: Employee Biweekly Premium(Required)

Biweekly Premium for Age 74

$25,000 | $93.36

$50,000 | $186.72

$75,000 | $280.08

$100,000 | $373.42 *Requires evidence of good health

N.A. | Waive Coverage

Age 75: Employee Biweekly Premium(Required)

Biweekly Premium for Age 75

$25,000 | $99.14

$50,000 | $198.28

$75,000 | $297.42

$100,000 | $396.54 *Requires evidence of good health

N.A. | Waive Coverage

Age 76: Employee Biweekly Premium(Required)

Biweekly Premium for Age 76

$25,000 | $122.26

$50,000 | $244.50

$75,000 | $366.76

$100,000 | $489.00 *Requires evidence of good health

N.A. | Waive Coverage

Age 77: Employee Biweekly Premium(Required)

Biweekly Premium for Age 77

$25,000 | $129.64

$50,000 | $259.26

$75,000 | $388.88

$100,000 | $518.50 *Requires evidence of good health

N.A. | Waive Coverage

Age 78: Employee Biweekly Premium(Required)

Biweekly Premium for Age 78

$25,000 | $135.60

$50,000 | $271.18

$75,000 | $406.76

$100,000 | $542.36 *Requires evidence of good health

N.A. | Waive Coverage

Age 79: Employee Biweekly Premium(Required)

Biweekly Premium for Age 79

$25,000 | $140.92

$50,000 | $281.82

$75,000 | $422.72

$100,000 | $563.62 *Requires evidence of good health

N.A. | Waive Coverage

Age 80: Employee Biweekly Premium(Required)

Biweekly Premium for Age 80

$25,000 | $146.54

$50,000 | $293.08

$75,000 | $439.62

$100,000 | $586.16 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 19: Employee Biweekly Premium(Required)

Biweekly Premium for Age 19

$50,000 | $7.70

$75,000 | $11.54

$100,000 | $15.40 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 20: Employee Biweekly Premium(Required)

Biweekly Premium for Age 20

$25,000 | $4.04

$50,000 | $8.08

$75,000 | $12.12

$100,000 | $16.16 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 21: Employee Biweekly Premium(Required)

Biweekly Premium for Age 21

$25,000 | $4.24

$50,000 | $8.46

$75,000 | $12.70

$100,000 | $16.94 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 22: Employee Biweekly Premium(Required)

Biweekly Premium for Age 22

$25,000 | $4.42

$50,000 | $8.86

$75,000 | $13.28

$100,000 | $17.70 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 23: Employee Biweekly Premium(Required)

Biweekly Premium for Age 23

$25,000 | $4.62

$50,000 | $9.24

$75,000 | $13.86

$100,000 | $18.46 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 24: Employee Biweekly Premium(Required)

Biweekly Premium for Age 24

$25,000 | $4.82

$50,000 | $9.62

$75,000 | $14.44

$100,000 | $19.24 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 25: Employee Biweekly Premium(Required)

Biweekly Premium for Age 25

$25,000 | $5.00

$50,000 | $10.00

$75,000 | $15.00

$100,000 | $20.00 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 26: Employee Biweekly Premium(Required)

Biweekly Premium for Age 26

$25,000 | $5.20

$50,000 | $10.40

$75,000 | $15.58

$100,000 | $20.78 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 27: Employee Biweekly Premium(Required)

Biweekly Premium for Age 27

$25,000 | $5.40

$50,000 | $10.78

$75,000 | $16.16

$100,000 | $21.54 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 28: Employee Biweekly Premium(Required)

Biweekly Premium for Age 28

$25,000 | $5.58

$50,000 | $11.16

$75,000 | $16.74

$100,000 | $22.32 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 29: Employee Biweekly Premium(Required)

Biweekly Premium for Age 29

$25,000 | $5.78

$50,000 | $11.54

$75,000 | $17.32

$100,000 | $23.08 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 30: Employee Biweekly Premium(Required)

Biweekly Premium for Age 30

$25,000 | $5.98

$50,000 | $11.92

$75,000 | $17.90

$100,000 | $23.86 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 31: Employee Biweekly Premium(Required)

Biweekly Premium for Age 31

$25,000 | $6.16

$50,000 | $12.32

$75,000 | $18.46

$100,000 | $24.62 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 32: Employee Biweekly Premium(Required)

Biweekly Premium for Age 32

$25,000 | $6.36

$50,000 | $12.70

$75,000 | $19.04

$100,000 | $25.40 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 33: Employee Biweekly Premium(Required)

Biweekly Premium for Age 33

$25,000 | $6.54

$50,000 | $13.08

$75,000 | $19.62

$100,000 | $26.16 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 34: Employee Biweekly Premium(Required)

Biweekly Premium for Age 34

$25,000 | $6.74

$50,000 | $13.48

$75,000 | $20.20

$100,000 | $26.92 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 35: Employee Biweekly Premium(Required)

Biweekly Premium for Age 35

$25,000 | $6.94

$50,000 | $13.86

$75,000 | $20.78

$100,000 | $27.70 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 36: Employee Biweekly Premium(Required)

Biweekly Premium for Age 36

$25,000 | $7.64

$50,000 | $15.26

$75,000 | $22.88

$100,000 | $30.50 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 37: Employee Biweekly Premium(Required)

Biweekly Premium for Age 37

$25,000 | $8.30

$50,000 | $16.60

$75,000 | $24.90

$100,000 | $33.20 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 38: Employee Biweekly Premium(Required)

Biweekly Premium for Age 38

$25,000 | $9.00

$50,000 | $18.00

$75,000 | $27.00

$100,000 | $36.00 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 39: Employee Biweekly Premium(Required)

Biweekly Premium for Age 39

$25,000 | $9.74

$50,000 | $19.48

$75,000 | $29.22

$100,000 | $38.98 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 40: Employee Biweekly Premium(Required)

Biweekly Premium for Age 40

$25,000 | $10.44

$50,000 | $20.88

$75,000 | $31.30

$100,000 | $41.74 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 41: Employee Biweekly Premium(Required)

Biweekly Premium for Age 41

$25,000 | $11.52

$50,000 | $23.04

$75,000 | $34.56

$100,000 | $46.08 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 42: Employee Biweekly Premium(Required)

Biweekly Premium for Age 42

$25,000 | $12.64

$50,000 | $25.26

$75,000 | $37.88

$100,000 | $50.50 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 43: Employee Biweekly Premium(Required)

Biweekly Premium for Age 43

$25,000 | $13.72

$50,000 | $27.44

$75,000 | $41.14

$100,000 | $54.86 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 44: Employee Biweekly Premium(Required)

Biweekly Premium for Age 44

$25,000 | $14.82

$50,000 | $29.64

$75,000 | $44.46

$100,000 | $59.28 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 45: Employee Biweekly Premium(Required)

Biweekly Premium for Age 45

$25,000 | $15.88

$50,000 | $31.76

$75,000 | $47.64

$100,000 | $63.50 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 46: Employee Biweekly Premium(Required)

Biweekly Premium for Age 46

$25,000 | $17.18

$50,000 | $34.34

$75,000 | $51.50

$100,000 | $68.66 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 47: Employee Biweekly Premium(Required)

Biweekly Premium for Age 47

$25,000 | $18.52

$50,000 | $37.04

$75,000 | $55.56

$100,000 | $74.08 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 48: Employee Biweekly Premium(Required)

Biweekly Premium for Age 48

$25,000 | $19.92

$50,000 | $39.84

$75,000 | $59.74

$100,000 | $79.66 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 49: Employee Biweekly Premium(Required)

Biweekly Premium for Age 49

$25,000 | $21.32

$50,000 | $42.62

$75,000 | $63.94

$100,000 | $85.24 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 50: Employee Biweekly Premium(Required)

Biweekly Premium for Age 50

$25,000 | $22.66

$50,000 | $45.34

$75,000 | $68.00

$100,000 | $90.66 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 51: Employee Biweekly Premium(Required)

Biweekly Premium for Age 51

$25,000 | $24.74

$50,000 | $49.48

$75,000 | $74.22

$100,000 | $98.98 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 52: Employee Biweekly Premium(Required)

Biweekly Premium for Age 52

$25,000 | $26.76

$50,000 | $53.52

$75,000 | $80.28

$100,000 | $107.04 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 53: Employee Biweekly Premium(Required)

Biweekly Premium for Age 53

$25,000 | $28.86

$50,000 | $57.72

$75,000 | $86.58

$100,000 | $115.42 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 54: Employee Biweekly Premium(Required)

Biweekly Premium for Age 54

$25,000 | $30.90

$50,000 | $61.80

$75,000 | $92.68

$100,000 | $123.58 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 55: Employee Biweekly Premium(Required)

Biweekly Premium for Age 55

$25,000 | $32.76

$50,000 | $65.52

$75,000 | $98.28

$100,000 | $131.04 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 56: Employee Biweekly Premium(Required)

Biweekly Premium for Age 56

$25,000 | $35.40

$50,000 | $70.80

$75,000 | $106.18

$100,000 | $141.58 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 57: Employee Biweekly Premium(Required)

Biweekly Premium for Age 57

$25,000 | $37.94

$50,000 | $75.86

$75,000 | $113.78

$100,000 | $151.70 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 58: Employee Biweekly Premium(Required)

Biweekly Premium for Age 58

$25,000 | $40.40

$50,000 | $80.78

$75,000 | $121.16

$100,000 | $161.54 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 59: Employee Biweekly Premium(Required)

Biweekly Premium for Age 59

$25,000 | $42.92

$50,000 | $85.84

$75,000 | $128.74

$100,000 | $171.66 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 60: Employee Biweekly Premium(Required)

Biweekly Premium for Age 60

$25,000 | $45.42

$50,000 | $90.84

$75,000 | $136.24

$100,000 | $181.66 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 61: Employee Biweekly Premium(Required)

Biweekly Premium for Age 61

$25,000 | $49.14

$50,000 | $98.28

$75,000 | $147.42

$100,000 | $196.54 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 62: Employee Biweekly Premium(Required)

Biweekly Premium for Age 62

$25,000 | $52.82

$50,000 | $105.62

$75,000 | $158.44

$100,000 | $211.24 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 63: Employee Biweekly Premium(Required)

Biweekly Premium for Age 63

$25,000 | $56.38

$50,000 | $112.74

$75,000 | $169.10

$100,000 | $225.46 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 64: Employee Biweekly Premium(Required)

Biweekly Premium for Age 64

$25,000 | $59.86

$50,000 | $119.70

$75,000 | $179.54

$100,000 | $239.40 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 65: Employee Biweekly Premium(Required)

Biweekly Premium for Age 65

$25,000 | $63.12

$50,000 | $126.22

$75,000 | $189.32

$100,000 | $252.44 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 66: Employee Biweekly Premium(Required)

Biweekly Premium for Age 66

$25,000 | $69.24

$50,000 | $138.48

$75,000 | $207.72

$100,000 | $276.96 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 67: Employee Biweekly Premium(Required)

Biweekly Premium for Age 67

$25,000 | $75.24

$50,000 | $150.46

$75,000 | $225.70

$100,000 | $300.94 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 68: Employee Biweekly Premium(Required)

Biweekly Premium for Age 68

$25,000 | $81.08

$50,000 | $162.16

$75,000 | $243.24

$100,000 | $324.32 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 69: Employee Biweekly Premium(Required)

Biweekly Premium for Age 69

$25,000 | $86.80

$50,000 | $173.60

$75,000 | $260.40

$100,000 | $347.20 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 70: Employee Biweekly Premium(Required)

Biweekly Premium for Age 70

$25,000 | $92.36

$50,000 | $184.72

$75,000 | $277.08

$100,000 | $369.44 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 71: Employee Biweekly Premium(Required)

Biweekly Premium for Age 71

$25,000 | $107.44

$50,000 | $214.88

$75,000 | $322.30

$100,000 | $429.74 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 72: Employee Biweekly Premium(Required)

Biweekly Premium for Age 72

$25,000 | $112.36

$50,000 | $224.72

$75,000 | $337.08

$100,000 | $449.44 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 73: Employee Biweekly Premium(Required)

Biweekly Premium for Age 73

$25,000 | $117.78

$50,000 | $235.54

$75,000 | $353.32

$100,000 | $471.08 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 74: Employee Biweekly Premium(Required)

Biweekly Premium for Age 74

$25,000 | $123.86

$50,000 | $247.70

$75,000 | $371.54

$100,000 | $495.40 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 75: Employee Biweekly Premium(Required)

Biweekly Premium for Age 75

$25,000 | $130.70

$50,000 | $261.40

$75,000 | $392.08

$100,000 | $522.78 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 76: Employee Biweekly Premium(Required)

Biweekly Premium for Age 76

$25,000 | $138.72

$50,000 | $277.42

$75,000 | $416.14

$100,000 | $554.86 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 77: Employee Biweekly Premium(Required)

Biweekly Premium for Age 77

$25,000 | $143.66

$50,000 | $287.32

$75,000 | $430.96

$100,000 | $574.62 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 78: Employee Biweekly Premium(Required)

Biweekly Premium for Age 78

$25,000 | $148.92

$50,000 | $297.82

$75,000 | $446.72

$100,000 | $595.62 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 79: Employee Biweekly Premium(Required)

Biweekly Premium for Age 79

$25,000 | $154.46

$50,000 | $308.90

$75,000 | $463.34

$100,000 | $617.78 *Requires evidence of good health

N.A. | Waive Coverage

TOBACCO Age 80: Employee Biweekly Premium(Required)

Biweekly Premium for Age 80

$25,000 | $160.28

$50,000 | $320.54

$75,000 | $480.82

$100,000 | $641.08 *Requires evidence of good health

N.A. | Waive Coverage

If Applicable, Would You Like Coverage For Your Spouse?

Name

First Last

Social Security Number for Spouse

Is Your Spouse a Tobacco User?

How Old Will Your Spouse be on January 1,2024

Age 18: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 18

$25,000 (Working) | $5.00

$50,000 (Working) | $10.00*Requires evidence of good health

$75,000 (Working) | $15.00*Requires evidence of good health

$100,000 (Working) | $20.00 *Requires evidence of good health

Age 19-25: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 19-25

$50,000 (Working) | $6.94*Requires evidence of good health

$75,000 (Working) | $10.40*Requires evidence of good health

$100,000 (Working) | $13.86 *Requires evidence of good health

Age 26: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 26

$50,000 (Working) | $7.04*Requires evidence of good health

$75,000 (Working) | $10.56*Requires evidence of good health

$100,000 (Working) | $14.08*Requires evidence of good health

Age 27: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 27

$50,000 (Working) | $7.16*Requires evidence of good health

$75,000 (Working) | $10.74*Requires evidence of good health

$100,000 (Working) | $14.32 *Requires evidence of good health

Age 28: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 28

$50,000 (Working) | $7.28*Requires evidence of good health

$75,000 (Working) | $10.92*Requires evidence of good health

$100,000 (Working) | $14.54 *Requires evidence of good health

Age 29: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 29

$50,000 (Working) | $7.40*Requires evidence of good health

$75,000 (Working) | $11.08*Requires evidence of good health

$100,000 (Working) | $14.78*Requires evidence of good health

Age 30: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 30

$50,000 (Working) | $7.50*Requires evidence of good health

$75,000 (Working) | $11.26*Requires evidence of good health

$100,000 (Working) | $15.00 *Requires evidence of good health

Age 31: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 31

$50,000 (Working) | $7.90*Requires evidence of good health

$75,000 (Working) | $11.84*Requires evidence of good health

$100,000 (Working) | $15.78 *Requires evidence of good health

Age 32: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 32

$25,000 (Working) | $4.14

$50,000 (Working) | $8.28*Requires evidence of good health

$75,000 (Working) |$12.42*Requires evidence of good health

$100,000 (Working) | $16.54 *Requires evidence of good health

Age 33: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 33

$25,000 (Working) | $4.34

$50,000 (Working) | $8.66 *Requires evidence of good health

$75,000 (Working) | $13.00 *Requires evidence of good health

$100,000 (Working) | $17.32 *Requires evidence of good health

Age 34: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 34

$25,000 (Working) | $4.52

$50,000 (Working) | $9.04 *Requires evidence of good health

$75,000 (Working) | $13.56 *Requires evidence of good health

$100,000 (Working)| $18.08 *Requires evidence of good health

Age 35: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 35

$25,000 (Working) | $4.72

$50,000 (Working) | 9.44*Requires evidence of good health

$75,000 (Working) | $14.14*Requires evidence of good health

$100,000 (Working) | $18.86 *Requires evidence of good health

Age 36: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 36

$25,000 (Working) | $4.92

$50,000 (Working) | $9.84*Requires evidence of good health

$75,000 (Working) | $14.74*Requires evidence of good health

$100,000 (Working) | $19.66 *Requires evidence of good health

Age 37: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 37

$25,000 (Working) | $5.34

$50,000 (Working) | $10.68*Requires evidence of good health

$75,000 (Working) | $16.02*Requires evidence of good health

$100,000 (Working) | $21.36 *Requires evidence of good health

Age 38: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 38

$25,000 (Working) | $5.74

$50,000 (Working) | $11.50*Requires evidence of good health

$75,000 (Working) | $17.22*Requires evidence of good health

$100,000 (Working) | $22.96*Requires evidence of good health

Age 39: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 39

$25,000 (Working) | $6.16

$50,000 (Working) | $12.30*Requires evidence of good health

$75,000 (Working) | $18.44*Requires evidence of good health

$100,000 (Working) | $24.58*Requires evidence of good health

Age 40: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 40

$25,000 (Working) | $6.56

$50,000 (Working) | $13.10*Requires evidence of good health

$75,000 (Working) | $19.66*Requires evidence of good health

$100,000 (Working) | $26.20*Requires evidence of good health

Age 41: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 41

$25,000 (Working) | $7.82

$50,000 (Working) | $14.38*Requires evidence of good health

$75,000 (Working) | $21.56*Requires evidence of good health

$100,000 (Working) | $28.74*Requires evidence of good health

Age 42: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 42

$25,000 (Working) | $7.82

$50,000 (Working) | $15.62*Requires evidence of good health

$75,000 (Working) | $23.44*Requires evidence of good health

$100,000 (Working) | $31.24*Requires evidence of good health

Age 43: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 43

$25,000 (Working) | $8.44

$50,000 (Working) | $16.88*Requires evidence of good health

$75,000 (Working) |$25.30*Requires evidence of good health

$100,000 (Working) | $33.74*Requires evidence of good health

Age 44: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 44

$25,000 (Working) | $9.08

$50,000 (Working) | $18.14*Requires evidence of good health

$75,000 (Working) | $27.22*Requires evidence of good health

$100,000 (Working) | $36.28*Requires evidence of good health

Age 45: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 45

$25,000 (Working) | $9.70

$50,000 (Working) | $19.40*Requires evidence of good health

$75,000 (Working) | $29.08*Requires evidence of good health

$100,000 (Working) | $38.78*Requires evidence of good health

Age 46: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 46

$10,000 (Non-Working) | $4.19

$25,000 (Working) | $10.48

$50,000 (Working) | $20.98*Requires evidence of good health

$75,000 (Working) | $31.46*Requires evidence of good health

$100,000 (Working) | $41.92*Requires evidence of good health

Age 47: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 47

$10,000 (Non-Working) | $4.50

$25,000 (Working) | $11.26

$50,000 (Working) | $22.52*Requires evidence of good health

$75,000 (Working) | $33.78*Requires evidence of good health

$100,000 (Working) | $45.04*Requires evidence of good health

Age 48: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 48

$10,000 (Non-Working) | $4.81

$25,000 (Working) | $12.04

$50,000 (Working) | $24.06*Requires evidence of good health

$75,000 (Working) | $36.10*Requires evidence of good health

$100,000 (Working) | $48.12*Requires evidence of good health

Age 49: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 49

$10,000 (Non-Working) | $5.12

$25,000 (Working) | $12.80

$50,000 (Working) | $25.60*Requires evidence of good health

$75,000 (Working) | $38.40*Requires evidence of good health

$100,000 (Working) | $51.20*Requires evidence of good health

Age 50: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 50

$10,000 (Non-Working) | $5.43

$25,000 (Working) | $13.58

$50,000 (Working) | $27.14*Requires evidence of good health

$75,000 (Working) |$40.72*Requires evidence of good health

$100,000 (Working) | $54.28*Requires evidence of good health

Age 51: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 51

$10,000 (Non-Working) | $5.99

$25,000 (Working) | $14.98

$50,000 (Working) | $29.96*Requires evidence of good health

$75,000 (Working) | $44.92*Requires evidence of good health

$100,000 (Working) | $59.90*Requires evidence of good health

Age 52: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 52

$10,000 (Non-Working) | $6.55

$25,000 (Working) | $16.40

$50,000 (Working) | $32.78*Requires evidence of good health

$75,000 (Working) | $49.16*Requires evidence of good health

$100,000 (Working) | $65.54*Requires evidence of good health

Age 53: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 53

$10,000 (Non-Working) | $7.12

$25,000 (Working) | $17.80

$50,000 (Working) | $35.58*Requires evidence of good health

$75,000 (Working) | $53.38*Requires evidence of good health

$100,000 (Working) | $71.16*Requires evidence of good health

Age 54: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 54

$10,000 (Non-Working) | $7.68

$25,000 (Working) | $19.20

$50,000 (Working) | $38.40*Requires evidence of good health

$75,000 (Working) | $57.58*Requires evidence of good health

$100,000 (Working) | $76.78*Requires evidence of good health

Age 55: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 55

$10,000 (Non-Working) | $8.65

$25,000 (Working) | $21.64

$50,000 | $43.28*Requires evidence of good health

$75,000 | $64.92*Requires evidence of good health

$100,000 | $86.54*Requires evidence of good health

Age 56: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 56

$10,000 (Non-Working) | $9.43

$25,000 (Working) | $23.60

$50,000 (Working) | $47.18*Requires evidence of good health

$75,000 (Working) | $70.76*Requires evidence of good health

$100,000 (Working) | $94.36*Requires evidence of good health

Age 57: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 57

$10,000 (Non-Working) | $10.21

$25,000 (Working) | $25.54

$50,000 (Working) | $51.08*Requires evidence of good health

$75,000 (Working) | $76.62*Requires evidence of good health

$100,000 (Working) | $102.16*Requires evidence of good health

Age 58: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 58

$10,000 (Non-Working) | $11.00

$25,000 (Working) | $27.50

$50,000 (Working) | $55.00*Requires evidence of good health

$75,000 (Working) | $82.48*Requires evidence of good health

$100,000 (Working) | $109.96*Requires evidence of good health

Age 59: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 59

$10,000 (Non-Working) | $11.78

$25,000 (Working) | $29.44

$50,000 (Working) | $58.90*Requires evidence of good health

$75,000 (Working) | $88.34*Requires evidence of good health

$100,000 (Working) | $117.78*Requires evidence of good health

Age 60: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 60

$10,000 (Non-Working) | $12.55

$25,000 (Working) | $31.38

$50,000 (Working) | $62.76*Requires evidence of good health

$75,000 (Working) | $94.14*Requires evidence of good health

$100,000 (Working) | $125.50*Requires evidence of good health

Age 61: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 61

$10,000 (Non-Working) | $13.76

$25,000 (Working) | $34.40

$50,000 (Working) | $68.80*Requires evidence of good health

$75,000 (Working) | $103.18*Requires evidence of good health

$100,000 (Working) | $137.58*Requires evidence of good health

Age 62: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 62

$10,000 (Non-Working) | $14.97

$25,000 (Working) | $37.42

$50,000 (Working) | $74.84*Requires evidence of good health

$75,000 (Working) | $112.24*Requires evidence of good health

$100,000 (Working) | $149.66*Requires evidence of good health

Age 63: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 63

$10,000 (Non-Working) | $16.18

$25,000 (Working) | $40.46

$50,000 (Working) | $80.90*Requires evidence of good health

$75,000 (Working) | $121.34*Requires evidence of good health

$100,000 (Working) | $161.78*Requires evidence of good health

Age 64: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 64

$10,000 (Non-Working) | $17.39

$25,000 (Working) | $43.48

$50,000 (Working) | $86.92*Requires evidence of good health

$75,000 (Working) | $130.40*Requires evidence of good health

$100,000 (Working) | $173.86*Requires evidence of good health

Age 65: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 65

$10,000 (Non-Working) | $18.59

$25,000 (Working) | $46.48

$50,000 (Working) | $92.98*Requires evidence of good health

$75,000 (Working) | $139.46*Requires evidence of good health

$100,000 (Working) | $185.92*Requires evidence of good health

Age 66: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 66

$10,000 (Non-Working) | $20.46

$25,000 (Working) | $51.14

$50,000 (Working) | $102.28*Requires evidence of good health

$75,000 (Working) | $153.42*Requires evidence of good health

$100,000 (Working) | $204.54*Requires evidence of good health

Age 67: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 67

$10,000 (Non-Working) | $22.31

$25,000 (Working) | $55.78

$50,000 (Working) | $111.56*Requires evidence of good health

$75,000 (Working) | $167.34*Requires evidence of good health

$100,000 (Working) | $223.12*Requires evidence of good health

Age 68: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 68

$10,000 (Non-Working) | $24.18

$25,000 (Working) | $60.44

$50,000 (Working) | $120.88*Requires evidence of good health

$75,000 (Working) | $181.30*Requires evidence of good health

$100,000 (Working) | $241.74*Requires evidence of good health

Age 69: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 69

$10,000 (Non-Working) | $26.03

$25,000 (Working) | $65.08

$50,000 (Working) | $130.16*Requires evidence of good health

$75,000 (Working) | $195.24*Requires evidence of good health

$100,000 (Working) | $260.32*Requires evidence of good health

Age 70: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 70

$10,000 (Non-Working) | $27.89

$25,000 (Working) | $69.72

$50,000 (Working) | $139.46*Requires evidence of good health

$75,000 (Working) | $209.18*Requires evidence of good health

$100,000 (Working) | $278.90*Requires evidence of good health

Age 71: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 71

$10,000 (Non-Working) | $32.82

$25,000 (Working) | $82.06

$50,000 (Working) | $164.12*Requires evidence of good health

$75,000 (Working) |$246.18*Requires evidence of good health

$100,000 (Working) | $328.24*Requires evidence of good health

Age 72: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 72

$10,000 (Non-Working) | $34.07

$25,000 (Working) | $85.18

$50,000 (Working) | $170.34*Requires evidence of good health

$75,000 (Working) | $255.50*Requires evidence of good health

$100,000 (Working) | $340.66*Requires evidence of good health

Age 73: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 73

$10,000 (Non-Working) | $35.41

$25,000 (Working) | $88.52

$50,000 (Working) | $177.04*Requires evidence of good health

$75,000 (Working) | $265.56*Requires evidence of good health

$100,000 (Working) | $354.08*Requires evidence of good health

Age 74: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 74

$10,000 (Non-Working) | $37.34

$25,000 (Working) | $93.36

$50,000 (Working) | $186.72*Requires evidence of good health

$75,000 (Working) | $280.08*Requires evidence of good health

$100,000 (Working) | $373.42*Requires evidence of good health

Age 75: Spouse Biweekly Premium

Spouse Semimonthly Premium for Age 75

$10,000 (Non-Working) | $39.66

$25,000 (Working) | $99.14

$50,000 (Working) | $198.28*Requires evidence of good health

$75,000 (Working) | $297.42*Requires evidence of good health

$100,000 (Working) | $396.54*Requires evidence of good health

Age 76: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 76

$10,000 (Non-Working) | $48.90

$25,000 (Working) | $122.26

$50,000 (Working) | $244.50*Requires evidence of good health

$75,000 (Working) |$366.76*Requires evidence of good health

$100,000 (Working) | $489.00*Requires evidence of good health

Age 77: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 77

$10,000 (Non-Working) | $51.85

$25,000 (Working) | $129.64

$50,000 (Working) | $259.26*Requires evidence of good health

$75,000 (Working) | $388.88*Requires evidence of good health

$100,000 (Working) | $518.50*Requires evidence of good health

Age 78: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 78

$10,000 (Non-Working) | $54.24

$25,000 (Working) | $135.60

$50,000 (Working) | $271.18*Requires evidence of good health

$75,000 (Working) | $406.76*Requires evidence of good health

$100,000 (Working)| $542.36*Requires evidence of good health

Age 79: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 79

$10,000 (Non-Working) | $56.36

$25,000 (Working) | $140.92

$50,000 (Working) | $281.82*Requires evidence of good health

$75,000 (Working) | $422.72*Requires evidence of good health

$100,000 (Working) | $563.62*Requires evidence of good health

Age 80: Spouse Biweekly Premium

Spouse Biweekly Premium for Age 80

$10,000 (Non-Working) | $58.62

$25,000 (Working) | $146.54

$50,000 (Working)| $293.08*Requires evidence of good health

$75,000 (Working) | $439.62*Requires evidence of good health

$100,000 (Working) | $586.16*Requires evidence of good health

TOBACCO Age 19 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 19

$50,000 (Working) | $7.70

$75,000 (Working) | $11.54*Requires evidence of good health

$100,000 (Working) | $15.40*Requires evidence of good health

TOBACCO Age 20 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 20

$25,000 (Working) | $4.04

$50,000 (Working) | $8.08*Requires evidence of good health

$75,000 (Working) | $12.12*Requires evidence of good health

$100,000 (Working) | $16.1*Requires evidence of good health6

TOBACCO Age 21 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 21

$25,000 (Working) | $4.24

$50,000 (Working) | $8.46*Requires evidence of good health

$75,000 (Working) | $12.70*Requires evidence of good health

$100,000 (Working) | $16.94*Requires evidence of good health

TOBACCO Age 22 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 22

$25,000 (Working) | $4.42

$50,000 (Working) | $8.86*Requires evidence of good health

$75,000 (Working) | $13.28*Requires evidence of good health

$100,000 (Working) | $17.70*Requires evidence of good health

TOBACCO Age 23 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 23

$25,000 (Working) | $4.62

$50,000 (Working) | $9.24*Requires evidence of good health

$75,000 (Working) | $13.86*Requires evidence of good health

$100,000 (Working) | $18.46*Requires evidence of good health

TOBACCO Age 24 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 24

$25,000 (Working) | $4.82

$50,000 (Working) | $9.62*Requires evidence of good health

$75,000 (Working) | $14.44*Requires evidence of good health

$100,000 (Working) | $19.24*Requires evidence of good health

TOBACCO Age 25 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 25

$25,000 (Working) | $5.00

$50,000 (Working) | $10.00*Requires evidence of good health

$75,000 (Working) | $15.00*Requires evidence of good health

$100,000 (Working) | $20.00*Requires evidence of good health

TOBACCO Age 26 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 26

$25,000 (Working) | $5.20

$50,000 (Working) | $10.40*Requires evidence of good health

$75,000 (Working) | $15.58*Requires evidence of good health

$100,000 (Working) | $20.78*Requires evidence of good health

TOBACCO Age 27 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 27

$25,000 (Working) | $5.40

$50,000 (Working) | $10.78*Requires evidence of good health

$75,000 (Working) | $16.16*Requires evidence of good health

$100,000 (Working) | $21.54*Requires evidence of good health

TOBACCO Age 28 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 28

$25,000 (Working) | $5.58

$50,000 (Working) | $11.16*Requires evidence of good health

$75,000 (Working) | $16.74*Requires evidence of good health

$100,000 (Working) | $22.32*Requires evidence of good health

TOBACCO Age 29 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 29

$25,000 (Working) | $5.78

$50,000 (Working) | $11.54*Requires evidence of good health

$75,000 (Working) | $17.32*Requires evidence of good health

$100,000 (Working) | $23.08*Requires evidence of good health

TOBACCO Age 30 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 30

$25,000 (Working) | $5.98

$50,000 (Working) | $11.92*Requires evidence of good health

$75,000 (Working) | $17.90*Requires evidence of good health

$100,000 (Working) | $23.86*Requires evidence of good health

TOBACCO Age 31 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 31

$25,000 (Working) | $6.16

$50,000 (Working) | $12.32*Requires evidence of good health

$75,000 (Working) | $18.46*Requires evidence of good health

$100,000 (Working) | $24.62*Requires evidence of good health

TOBACCO Age 32 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 32

$25,000 (Working) | $6.36

$50,000 (Working) | $12.70*Requires evidence of good health

$75,000 (Working) | $19.04*Requires evidence of good health

$100,000 (Working) | $25.40*Requires evidence of good health

TOBACCO Age 33 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 33

$25,000 (Working) | $6.54

$50,000 (Working) | $13.08*Requires evidence of good health

$75,000 (Working) | $19.62*Requires evidence of good health

$100,000 (Working) | $26.16*Requires evidence of good health

TOBACCO Age 34 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 34

$25,000 (Working) | $6.74

$50,000 (Working) | $13.48*Requires evidence of good health

$75,000 (Working) | $20.20*Requires evidence of good health

$100,000 (Working) | $26.92*Requires evidence of good health

TOBACCO Age 35 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 35

$25,000 (Working) | $6.94

$50,000 (Working) | $13.86*Requires evidence of good health

$75,000 (Working) | $20.78*Requires evidence of good health

$100,000 (Working) | $27.70*Requires evidence of good health

TOBACCO Age 36 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 36

$25,000 (Working) | $7.64

$50,000 (Working) | $15.26*Requires evidence of good health

$75,000 (Working) | $22.88*Requires evidence of good health

$100,000 (Working) | $30.50*Requires evidence of good health

TOBACCO Age 37 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 37

$25,000 (Working) | $8.30

$50,000 (Working) | $16.60*Requires evidence of good health

$75,000 (Working) | $24.90*Requires evidence of good health

$100,000 (Working) | $33.20*Requires evidence of good health

TOBACCO Age 38 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 38

$25,000 (Working) | $9.00

$50,000 (Working) | $18.00*Requires evidence of good health

$75,000 (Working) | $27.00*Requires evidence of good health

$100,000 (Working) | $36.00*Requires evidence of good health

TOBACCO Age 39 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 39

$25,000 (Working) | $9.74

$50,000 (Working) | $19.48*Requires evidence of good health

$75,000 (Working) | $29.22*Requires evidence of good health

$100,000 (Working) | $38.98*Requires evidence of good health

TOBACCO Age 40 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 40

$10,000 (Non-Working) | $4.17

$25,000 (Working) | $10.44

$50,000 (Working) | $20.88*Requires evidence of good health

$75,000 (Working) | $31.30*Requires evidence of good health

$100,000 (Working) | $41.74*Requires evidence of good health

TOBACCO Age 41 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 41

$10,000 (Non-Working) | $4.61

$25,000 (Working) | $11.52

$50,000 (Working) | $23.04*Requires evidence of good health

$75,000 (Working) | $34.56*Requires evidence of good health

$100,000 (Working) | $46.08*Requires evidence of good health

TOBACCO Age 42 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 42

$10,000 (Non-Working) | $5.05

$25,000 (Working) | $12.64

$50,000 (Working) | $25.26*Requires evidence of good health

$75,000 (Working) | $37.88*Requires evidence of good health

$100,000 (Working) | $50.50*Requires evidence of good health

TOBACCO Age 43 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 43

$10,000 (Non-Working) | $5.48

$25,000 (Working) | $13.72

$50,000 (Working) | $27.44*Requires evidence of good health

$75,000 (Working) | $41.14*Requires evidence of good health

$100,000 (Working) | $54.86*Requires evidence of good health

TOBACCO Age 44 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 44

$10,000 (Non-Working) | $5.93

$25,000 (Working) | $14.82

$50,000 (Working) | $29.64*Requires evidence of good health

$75,000 (Working) | $44.46*Requires evidence of good health

$100,000 (Working) | $59.28*Requires evidence of good health

TOBACCO Age 45 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 45

$10,000 (Non-Working) | $6.35

$25,000 (Working) | $15.88

$50,000 (Working) | $31.76*Requires evidence of good health

$75,000 (Working) | $47.64*Requires evidence of good health

$100,000 (Working) | $63.50*Requires evidence of good health

TOBACCO Age 46 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 46

$10,000 (Non-Working) | $6.87

$25,000 (Working) | $17.18

$50,000 (Working) | $34.34*Requires evidence of good health

$75,000 (Working) | $51.50*Requires evidence of good health

$100,000 (Working) | $68.66*Requires evidence of good health

TOBACCO Age 47 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 47

$10,000 (Non-Working) | $7.41

$25,000 (Working) | $18.52

$50,000 (Working) | $37.04*Requires evidence of good health

$75,000 (Working) | $55.56*Requires evidence of good health

$100,000 (Working) | $74.08*Requires evidence of good health

TOBACCO Age 48 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 48

$10,000 (Non-Working) | $7.97

$25,000 (Working) | $19.92

$50,000 (Working) | $39.84*Requires evidence of good health

$75,000 (Working) | $59.74*Requires evidence of good health

$100,000 (Working) | $79.66*Requires evidence of good health

TOBACCO Age 49 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 49

$10,000 (Non-Working) | $8.52

$25,000 (Working) | $21.32

$50,000 (Working) | $42.62*Requires evidence of good health

$75,000 (Working) | $63.94*Requires evidence of good health

$100,000 (Working) | $85.24*Requires evidence of good health

TOBACCO Age 50 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 50

$10,000 (Non-Working) | $9.06

$25,000 (Working) | $22.66

$50,000 (Working) | $45.34*Requires evidence of good health

$75,000 (Working) | $68.00*Requires evidence of good health

$100,000 (Working) | $90.66*Requires evidence of good health

TOBACCO Age 51 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 51

$10,000 (Non-Working) | $9.90

$25,000 (Working) | $24.74

$50,000 (Working) | $49.48*Requires evidence of good health

$75,000 (Working) | $74.22*Requires evidence of good health

$100,000 (Working) | $98.98*Requires evidence of good health

TOBACCO Age 52 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 52

$10,000 (Non-Working) | $10.70

$25,000 (Working) | $26.76

$50,000 (Working) | $53.52*Requires evidence of good health

$75,000 (Working) | $80.28*Requires evidence of good health

$100,000 (Working) | $107.04*Requires evidence of good health

TOBACCO Age 53 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 53

$10,000 (Non-Working) | $11.54

$25,000 (Working) | $28.86

$50,000 (Working) | $57.72*Requires evidence of good health

$75,000 (Working) | $86.58*Requires evidence of good health

$100,000 (Working) | $115.42*Requires evidence of good health

TOBACCO Age 54 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 54

$10,000 (Non-Working) | $12.36

$25,000 (Working) | $30.90

$50,000 (Working) | $61.80*Requires evidence of good health

$75,000 (Working) | $92.68*Requires evidence of good health

$100,000 (Working) | $123.58*Requires evidence of good health

TOBACCO Age 55 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 55

$10,000 (Non-Working) | $13.10

$25,000 (Working) | $32.76

$50,000 (Working) | $65.52*Requires evidence of good health

$75,000 (Working) | $98.28*Requires evidence of good health

$100,000 (Working) | $131.04*Requires evidence of good health

TOBACCO Age 56 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 56

$10,000 (Non-Working) | $14.16

$25,000 (Working) | $35.40

$50,000 (Working) | $70.80*Requires evidence of good health

$75,000 (Working) | $106.18*Requires evidence of good health

$100,000 (Working) | $141.58*Requires evidence of good health

TOBACCO Age 57 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 57

$10,000 (Non-Working) | $15.17

$25,000 (Working) | $37.94

$50,000 (Working) | $75.86*Requires evidence of good health

$75,000 (Working) | $113.78*Requires evidence of good health

$100,000 (Working) | $151.70*Requires evidence of good health

TOBACCO Age 58 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 58

$10,000 (Non-Working) | $16.15

$25,000 (Working) | $37.94

$50,000 (Working) | $80.78*Requires evidence of good health

$75,000 (Working) | $121.16*Requires evidence of good health

$100,000 (Working) | $161.54*Requires evidence of good health

TOBACCO Age 59 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 59

$10,000 (Non-Working) | $17.16

$25,000 (Working) | $42.92

$50,000 (Working) | $85.84*Requires evidence of good health

$75,000 (Working) | $128.74*Requires evidence of good health

$100,000 (Working) | $171.66*Requires evidence of good health

TOBACCO Age 60 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 60

$10,000 (Non-Working) | $18.17

$25,000 (Working) | $45.42

$50,000 (Working) | $90.84*Requires evidence of good health

$75,000 (Working) | $136.24*Requires evidence of good health

$100,000 (Working) | $181.66*Requires evidence of good health

TOBACCO Age 61 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 61

$10,000 (Non-Working) | $19.65

$25,000 (Working) | $49.14

$50,000 (Working) | $98.28*Requires evidence of good health

$75,000 (Working) | $147.42*Requires evidence of good health

$100,000 (Working) | $196.54*Requires evidence of good health

TOBACCO Age 62 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 62

$10,000 (Non-Working) | $21.12

$25,000 (Working) | $52.82

$50,000 (Working) | $105.62*Requires evidence of good health

$75,000 (Working) | $158.44*Requires evidence of good health

$100,000 (Working) | $211.24*Requires evidence of good health

TOBACCO Age 63 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 63

$10,000 (Non-Working) | $22.55

$25,000 (Working) | $56.38

$50,000 (Working) | $112.74*Requires evidence of good health

$75,000 (Working) | $169.10*Requires evidence of good health

$100,000 (Working) | $225.46*Requires evidence of good health

TOBACCO Age 64 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 64

$10,000 (Non-Working) | $23.94

$25,000 (Working) | $59.86

$50,000 (Working) | $119.70*Requires evidence of good health

$75,000 (Working) | $179.54*Requires evidence of good health

$100,000 (Working) | $239.40*Requires evidence of good health

TOBACCO Age 65 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 65

$10,000 (Non-Working) | $25.24

$25,000 (Working) | $63.12

$50,000 (Working) | $126.22*Requires evidence of good health

$75,000 (Working) | $189.32*Requires evidence of good health

$100,000 (Working) | $252.44*Requires evidence of good health

TOBACCO Age 66 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 66

$10,000 (Non-Working) | $27.70

$25,000 (Working) | $69.24

$50,000 (Working) | $138.48*Requires evidence of good health

$75,000 (Working) | $207.72*Requires evidence of good health

$100,000 (Working) | $276.96*Requires evidence of good health

TOBACCO Age 67 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 67

$10,000 (Non-Working) | $30.09

$25,000 (Working) | $75.24

$50,000 (Working) | $150.46*Requires evidence of good health

$75,000 (Working) | $225.70*Requires evidence of good health

$100,000 (Working) | $300.94*Requires evidence of good health

TOBACCO Age 68 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 68

$10,000 (Non-Working) | $32.43

$25,000 (Working) | $81.08

$50,000 (Working) | $162.16*Requires evidence of good health

$75,000 (Working) | $243.24*Requires evidence of good health

$100,000 (Working) | $324.32*Requires evidence of good health

TOBACCO Age 69 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 69

$10,000 (Non-Working) | $34.72

$25,000 (Working) | $86.80

$50,000 (Working) | $173.60*Requires evidence of good health

$75,000 (Working) | $260.40*Requires evidence of good health

$100,000 (Working) | $347.20*Requires evidence of good health

TOBACCO Age 70 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 70

$10,000 (Non-Working) | $36.94

$25,000 (Working) | $92.36

$50,000 (Working) | $184.72*Requires evidence of good health

$75,000 (Working) | $277.08*Requires evidence of good health

$100,000 (Working) | $369.44*Requires evidence of good health

TOBACCO Age 71 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 71

$10,000 (Non-Working) | $42.97

$25,000 (Working) | $107.44

$50,000 (Working) | $214.88*Requires evidence of good health

$75,000 (Working) | $322.30*Requires evidence of good health

$100,000 (Working) | $429.74*Requires evidence of good health

TOBACCO Age 72 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 72

$10,000 (Non-Working) | $44.94

$25,000 (Working) | $112.36

$50,000 (Working) | $224.72*Requires evidence of good health

$75,000 (Working) | $337.08*Requires evidence of good health

$100,000 (Working) | $449.44*Requires evidence of good health

TOBACCO Age 73 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 73

$10,000 (Non-Working) | $47.11

$25,000 (Working) | $117.78

$50,000 (Working) | $235.54*Requires evidence of good health

$75,000 (Working) | $353.32*Requires evidence of good health

$100,000 (Working) | $471.08*Requires evidence of good health

TOBACCO Age 74 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 74

$10,000 (Non-Working) | $49.54

$25,000 (Working) | $117.78

$50,000 (Working) | $247.70*Requires evidence of good health

$75,000 (Working) | $371.54*Requires evidence of good health

$100,000 (Working) | $495.40*Requires evidence of good health

TOBACCO Age 75 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 75

$10,000 (Non-Working) | $52.28

$25,000 (Working) | $130.70

$50,000 (Working) | $261.40*Requires evidence of good health

$75,000 (Working) | $392.08*Requires evidence of good health

$100,000 (Working) | $522.78*Requires evidence of good health

TOBACCO Age 76 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 76

$10,000 (Non-Working) | $55.49

$25,000 (Working) | $138.72

$50,000 (Working) | $277.42*Requires evidence of good health

$75,000 (Working) | $416.14*Requires evidence of good health

$100,000 (Working) | $554.89*Requires evidence of good health

TOBACCO Age 77 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 77

$10,000 (Non-Working) | $57.46

$25,000 (Working) | $143.66

$50,000 (Working) | $287.32*Requires evidence of good health

$75,000 (Working) | $430.96*Requires evidence of good health

$100,000 (Working) | $574.62*Requires evidence of good health

TOBACCO Age 78 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 78

$10,000 (Non-Working) | $59.56

$25,000 (Working) | $148.92

$50,000 (Working) | $297.82*Requires evidence of good health

$75,000 (Working) | $446.72*Requires evidence of good health

$100,000 (Working) | $595.62*Requires evidence of good health

TOBACCO Age 79 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 79

$10,000 (Non-Working) | $61.78

$25,000 (Working) | $154.46

$50,000 (Working) | $308.90*Requires evidence of good health

$75,000 (Working) | $463.34*Requires evidence of good health

$100,000 (Working) | $617.78*Requires evidence of good health

TOBACCO Age 80 : Spouse Biweekly Premium

Spouse Biweekly Premium for Age 80

$10,000 (Non-Working) | $64.11

$25,000 (Working) | $160.28

$50,000 (Working) | $320.54*Requires evidence of good health

$75,000 (Working) | $480.82*Requires evidence of good health

$100,000 (Working) | $641.08*Requires evidence of good health

If Applicable, Would You Like Coverage For Your Child(ren)?

Please Enter Your Child(ren)'s Name

First & Last Name

Date of Birth

Biweekly Child(ren)

Biweekly Premium for Child(ren) Riders

10,000 (Under Age 26) | $2.10

20,000 (Under Age 26) | $4.20

Please Enter Your Beneficiaries(Required)

First & Last Name

Relationship

I acknowledge the opportunity Altra Federal Credit Union has given me to enroll in term to age 100 life insurance coverage. If selecting coverage, I authorize Altra Federal Credit Union to deduct the above premiums from my paycheck. If waiving, I understand I will not have another opportunity to enroll until the next open enrollment or if I have a qualifying event. Proof of good health will be required. Additional plan information can be found in the Altra Federal Credit Union benefits portal.

Coverage Effective January 1, 2024

Term to Age 100 Life Insurance

Traditional Term Life Insurance will have rate increases as you age, this Term Life Insurance will never have a rate increase to age 100. Lock in this bi-weekly premium as soon as you can when it’s most affordable!

Altra Federal Credit Union Term to 100 Life Insurance Form

For Questions, Contact enrollmentquestions@ticinsurance.com