Download Cost Worksheet --NMS

Cost Worksheet --NMS
This worksheet is designed to assist you in determining your benefit options and the associated costs for
insurance for the current plan year.
All costs are based on a semi-monthly pay period.
Contributions for voluntary employee life and spouse life are based on age as of January 1st.
Your costs for long-term disability and short-term disability may change based on your W2 earnings for the
previous calendar year. Please refer to your Summary Plan Description for your definition of earnings.
Medical 12/1/14
Coverage
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee & Family
Rates per PayCheck
$100.80
$389.61
$284.48
$616.34
Dental 12/1/14
Coverage
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee & Family
Rates per PayCheck
$19.05
$43.10
$45.32
$71.82
Vision Basic 1/1/15
Coverage
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee & Family
Rates per PayCheck
$0.00
$0.00
$0.00
$0.00
Vision Buy-Up 1/1/15
Coverage
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee & Family
Rates per PayCheck
$6.12
$10.02
$10.22
$16.48
12/1/14
Short-Term Disability (STD)* *The STD cost is subject to change if the 50% participation requirement is not met.
Benefit
60% of weekly earnings to a maximum of $1,500 per week
Cost per $10 of Covered Weekly Benefit
$0.48
W2 Earnings: $___________ / by 52 weeks x 60% = ___________(Weekly Benefit Amount)
Weekly Benefit Amount $___________ / by 10 = ___________x $0.50 (Rate) = ___________ (Monthly Cost)
Monthly Cost _____________ / 2 =___________ (Per Pay Period Cost)
Long-Term Disability (LTD) 12/1/14
Benefit
60% of monthly earnings to a maximum of $10,000 per month
Cost per $100 of Covered Monthly Benefit
$0.373
W2 Earnings: $___________ / by 12 months = ___________ (Monthly Benefit Amount)
Monthly Benefit Amount $___________ / by 100 =___________ x $0.355 (Rate) = ___________ (Monthly Cost)
Monthly Cost _____________ / 2 = ___________ (Per Pay Period Cost)
Employee Voluntary Life Insurance 12/1/14
Increments of $10,000 up to maximum of $500,000. Guarantee Issue amount is $150,000.
Age
<30
30-34
35-39
40-44
45-49
50-54
Rate per $1,000
$0.08
$0.09
$0.12
$0.18
$0.30
$0.51
Coverage Amount Requested: $___________
55-59
$0.78
60-64
$1.23
65-69
$2.21
70+
$3.94
Your Rate By Age: ___________
Coverage Amount Requested Divided by 1,000 = __________ (Multiplier)
__________ (Multiplier) x __________ (Your Rate) =__________ (Monthly Cost) / 2 = ______________ (Per Pay Period Cost)
Spouse Life Insurance Increments of $10,000 up to maximum of $250,000. Guarantee Issue amount is $20,000. 12/1/14
Age
<30
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70+
Rate per $1,000
$0.08
$0.09
$0.12
$0.18
$0.30
$0.51
$0.78
$1.23
$2.21 $3.94
Coverage Amount Requested: $ __________Your Spouse's Rate By Age: __________
Coverage Amount Requested Divided by 1,000 =__________ (Multiplier)
__________ (Multiplier) x __________ (Your Rate) =__________ (Monthly Cost) / 2 = ______________ (Per Pay Period Cost)
(Spouse life insurance cannot exceed 50% of employee coverage.)
Child Life Insurance 12/1/14
Coverage
Per Pay Period Cost
$2,500
$5,000
$7,500
$10,000
$0.23
$0.45
$0.68
$0.90
Decline
Coverage
$0.00