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<br />Dependents Life Insurance: <br /> <br />$XXX monthly per Member electing Dependents Life Insurance, <br />regardless of the number of Dependents covered. <br /> <br />Supplemental Life Insurance: <br />Age of Insured On <br />Last January 1 <br /> <br />Under 30 <br />30 through 39 <br />40 through 44 <br />45 through 49 <br />50 through 54 <br />55 through 59 <br />60 through 64, <br />65 through 69 <br />70 through 74 <br />75 through 79 <br />80 through 84 <br />85 through 89 <br />90 through 94 <br />95 or over <br /> <br />Monthly Rate Per <br />Multiple of$10,000 <br /> <br />$ 1.00 <br />1.10 <br />2.20 <br />3.90 <br />6.40 <br />9.90 <br />14.80 <br />22.30 <br />34.30 <br />49.55 <br />74.35 <br />111.50 <br />148.65 <br />223.00 <br /> <br />Premium Due Dates: <br />Grace Period: <br />lDitial Rate Guarantee Period: <br /> <br />June 1, 1995 and the first day of each calendar month thereafter. <br />31 days <br />Supplemental Life Insurance: None <br /> <br />All other insurance: 1 year <br /> <br />31 days <br /> <br />Notice of Rate Change: <br />Minimum Participation <br />Life Insurance: <br />Number: <br />Percentage: <br />Supplemental Life Insurance: <br />Dependents Life Insurance: <br /> <br />10 iDsured Members <br />100% of eligible Members <br />Not applicable. <br />Not applicable. <br /> <br />Printed 4196 Revised 4196 <br /> <br />-4- <br /> <br />SAMPLE U,AD&D, DU, Sup. U <br />