2025 Benefits Election Form

EMPLOYEE INFORMATION:
COMPANY NAME: DATE OF HIRE: DATE OF BIRTH (MM/DD/YYYY):
TAV Holdings, Inc.
LAST NAME: FIRST NAME: SSN:

STREET ADDRESS: CITY/STATE: ZIP:

GENDER: If Name or Address has changed, please check box

MALE FEMALE

Amounts Shown are WEEKLY.

If you are paid on a Bi-Weekly basis, simply double the amounts shown for your deduction.
All deductions are taken on a pre-tax basis.
CIGNA MEDICAL PLANS
$6,250 HDHP HSA-Eligible Plan $3,500 Copay Plan

EE $52.32 EE $96.06
ES $217.76 ES $309.62
EC $195.20 EC $280.50
FF $360.64 FF $494.05

WAIVE MEDICAL

Weekly Rates

CIGNA DENTAL PLAN CIGNA VISION PLAN

EE $7.98 EE $1.62
ES $15.95 ES $3.09
EC $18.67 EC $3.25
FF $28.06 FF $4.77
WAIVE DENTAL WAIVE VISION

EE = Employee ONLY, ES = Employee + Spouse ONLY, EC = Employee + Child(ren) ONLY,

FF = Full Family/Employee, Spouse, AND Child(ren)
 2025 Benefits Election Form
ONLY LIST DEPENDENTS IF YOU ARE COVERING THEM UNDER YOUR MEDICAL, DENTAL, AND/OR
VISION PLANS; OTHERWISE, LEAVE BLANK IF YOU’RE ONLY ELECTING COVERAGE FOR YOURSELF
DEPENDENT INFORMATION:
SPOUSE: MEDICAL DENTAL VISION

LAST NAME: FIRST NAME:

MALE FEMALE SSN: DOB:

CHILD 1: MEDICAL DENTAL VISION

LAST NAME: FIRST NAME:

MALE FEMALE SSN: DOB:

CHILD 2: MEDICAL DENTAL VISION

LAST NAME: FIRST NAME:

MALE FEMALE SSN: DOB:

CHILD 3: MEDICAL DENTAL VISION

LAST NAME FIRST NAME:

MALE FEMALE SSN: DOB:

CHILD 4: MEDICAL DENTAL VISION

LAST NAME FIRST NAME:

MALE FEMALE SSN: DOB:

CHILD 5: MEDICAL DENTAL VISION

LAST NAME FIRST NAME:

MALE FEMALE SSN: DOB:

I authorize the appropriate adjustment to my paycheck based on my elections above. I understand that by
electing medical, dental, and vision deduction on a pre-tax basis and by signing and submitting this form that I
am making a binding election for the 2025 plan year unless such revocation or new election is on account and
consistent with a change in status (e.g., marriage, divorce, death, or termination of employment).

Signed: ________________________________________ Date: ____________________________

 TAV Holdings
Group Number :

Enrollment Form
EMPLOYEE INFORMATION. Please verify the information below for accuracy. If incorrect, please contact your HR representative.
Date of Birth Employee ID/SSN
Name/Address
Division Date of Hire

BillClass SubGroup

Effective Date Gender

PLEASE PRINT IN BLACK OR BLUE INK. Read and complete all of this form. Please complete all grayed sections. If you need more
space, attach a separate sheet of paper. Please use four digits for years (e.g. 1998, not 98).

Are you actively at work? Yes No

Are you retired? Yes No
Marital status: Single Married Widowed Divorced
Occupation:

Phone:
Hours per week working for this employer: Email Address:

BENEFIT SELECTION. Check the boxes that apply along with the appropriate coverage level.
Voluntary Life and AD&D Voluntary Life allows you to expand and enhance your benefits through convenient payroll
deduction. Voluntary life gives you the opportunity to purchase life insurance coverage for
yourself at a fraction of what insurance would cost in the individual market place. Amounts
elected over $100,000 will require an evidence of insurability form to be completed.
Accept Decline You may elect $10,000 increments to a maximum of 350,000, limited to 5 times annual
earnings. Please select a benefit amount from below or select one from the attached rate
matrix.

Guaranteed Issue
Other Benefit

Coverage Amount $100,000.00 $70,000.00 $30,000.00

Weekly Premium

Semi-Monthly Premium

Reduction Schedule : By 33% at age 70; By 66% at age 75. Benefits terminate at retirement

ABCBS-9116 (05/10) Page 1 of 5

Voluntary Spouse/Domestic You may elect increments of $5,000 to a maximum of $175,000 not to exceed 50% of the
Partner Dependent Life employee benefit amount. You must elect Voluntary employee life in order to purchase the
dependent coverage. Spouse/Domestic Partner amounts elected over $25,000 will require an
evidence of insurability form to be completed.

You may elect $5,000 increments to a maximum of $175,000. You can elect one of the
following benefit amounts or select another amount from the rate matrix.
Accept Decline
Guaranteed Issue Other Benefit

Coverage Amount $25,000.00 $15,000.00

Weekly Premium

Semi-Monthly Premium

Reduction Schedule : By 33% at age 70; By 66% at age 75. Benefits terminate at retirement

Voluntary Child(ren) You may elect increments of $5,000 to a maximum of $10,000 not to exceed 50% of the
Dependent Life employee benefit amount. You must elect Voluntary employee life in order to purchase the
dependent coverage.

You may elect $5,000 increments to a maximum of $10,000. You can elect one of the
following benefit amounts.

Accept Decline
Guaranteed Issue

Coverage Amount $10,000.00 $5,000.00

Weekly Premium $0.48 $0.24

Semi-Monthly Premium $1.04 $0.52

*Child Coverage from 15 days to Age 26.

Voluntary STD Voluntary STD insurance helps to replace your income if you are sick or injured and cannot
work. This coverage commences on the 1st day of accident or the 8th day of sickness and is
designed to continue for a period of up to 13 weeks. The plan provides income protection to
replace 60% of your weekly earnings up to a maximum of $1,500.
Accept Decline

Weekly Weekly Semi-Monthly

Benefit Amount Premium Premium

ABCBS-9116 (05/10) Page 2 of 5

Voluntary LTD Voluntary LTD allows you to purchase coverage to protect your income should you become
disabled after a 90 day waiting period. You can choose to protect up to 60% of your monthly
earnings up to a maximum of $5,000. Your ability to earn income is your greatest asset and
Long Term Disability allows you to protect your income.

Accept Decline

Monthly Weekly Semi-Monthly

Benefit Amount Premium Premium

Accident This coverage provides fixed benefits for specific medical services or events caused or contributed to by an
accident.
Coverage Level Weekly Premium Semi-Monthly Premium

Accept Decline Employee Only $2.01 $4.36

Employee + Spouse $3.24 $7.02

Choose One Employee + Child (ren) $3.44 $7.45

Employee + Family $5.43 $11.76

You must indicate Coverage Level

Critical Illness This coverage provides lump sum benefits for the occurrence or diagnosis of specific illness.
$10,000 Benefit
Coverage Level Bi-Weekly Premium Semi-Monthly Premium

Accept Decline Employee Only

Employee + Spouse

Choose One Employee + Child (ren)

You must indicate Coverage Level
Employee + Family

If any person to be covered by a Critical Illness or Hospital Indemnity plan is a resident of CA, GA, NY or CO, please answer the following question:
Will all applicants who reside in CA, GA, NY or CO, when such coverage is to become effective, be enrolled in comprehensive health benefits from an individual or
group health insurance policy, an employer sponsored health plan, or an HMO that provides essential health benefits?
(Please note that if the response is No, such applicants are not eligible for coverage) Yes No

Critical Illness This coverage provides lump sum benefits for the occurrence or diagnosis of specific illness.
$20,000 Benefit
Coverage Level Bi-Weekly Premium Semi-Monthly Premium

Accept Decline Employee Only

Employee + Spouse

Choose One Employee + Child (ren)

You must indicate Coverage Level
Employee + Family

If any person to be covered by a Critical Illness or Hospital Indemnity plan is a resident of CA, GA, NY or CO, please answer the following question:
Will all applicants who reside in CA, GA, NY or CO, when such coverage is to become effective, be enrolled in comprehensive health benefits from an individual or
group health insurance policy, an employer sponsored health plan, or an HMO that provides essential health benefits?
(Please note that if the response is No, such applicants are not eligible for coverage) Yes No

ABCBS-9116 (05/10) Page 3 of 5

Critical Illness This coverage provides lump sum benefits for the occurrence or diagnosis of specific illness.
$30,000 Benefit
Coverage Level Bi-Weekly Premium Semi-Monthly Premium

Accept Decline Employee Only

Employee + Spouse

Choose One Employee + Child (ren)

You must indicate Coverage Level
Employee + Family

If any person to be covered by a Critical Illness or Hospital Indemnity plan is a resident of CA, GA, NY or CO, please answer the following question:
Will all applicants who reside in CA, GA, NY or CO, when such coverage is to become effective, be enrolled in comprehensive health benefits from an individual or
group health insurance policy, an employer sponsored health plan, or an HMO that provides essential health benefits?
(Please note that if the response is No, such applicants are not eligible for coverage) Yes No

DEPENDENT DESIGNATION
(Complete all details for Individuals applying for coverage: list names of all dependents.)

SSN Sex Date of Birth Relationship

Last name, First name, M.I. Age
(XXX-XX-XXXX) (XX-XX-XXXX) (spouse/domestic partner or child)

M Spouse/Domestic Partner
- - / /
F
M
- - / / Child
F
M
- - F
/ / Child

M
- - / / Child
F

M
- - / / Child
F

List address of all dependents if different from the applicant, including temporary address, e.g. college student.

Name/Address: /

Name/Address: /

ABCBS-9116 (05/10) Page 4 of 5

BENEFICIARY DESIGNATION
It is important that your beneficiary designation is clear. It is also important that you name a primary beneficiary and contingent beneficiary. If
the beneficiary is not related to you by either blood or marriage, please insert the words 'Not Related' in the relationship box.

NOTE: Please complete the section below for Employee Coverage ONLY. You “the employee” will always be considered the
beneficiary for the Dependent Life Insurance when elected.
EMPLOYEE BENEFICIARY DESIGNATION In equal shares unless otherwise provided below

Last name First name, M.I. Social Security # Relationship to Applicant Age %
Primary
Beneficiary _ _

Primary Last name First name, M.I. Social Security # Relationship to Applicant Age %
Beneficiary
_ _

In equal shares unless otherwise provided below

Contingent Last name First name, M.I. Social Security # Relationship to Applicant Age %
Beneficiary
_ _

Contingent Last name First name, M.I. Social Security # Relationship to Applicant Age %
Beneficiary
_ _

ELIGIBILITY AND AUTHORIZATION

Employee Confirmation

My signature certifies that I (1) Apply for the coverages designated for which I am eligible under my employer’s plan with the carrier. (2) Understand if
coverages have been refused, I am not entitled to benefits under those coverages and that if I want to apply later, I must furnish at my own expense proof
of good health to the carrier. (3) Authorize any required deductions from my earnings. (4) Designate the beneficiary named on this application to receive
any benefits payable in the event of death. (5) Represent that all of the information on this application is complete, correct and true to the best of my
knowledge and belief. (6) Understand that I must be actively at work the number of hours specified in the policy/participation agreement to remain insured.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim
containing materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent
insurance act, which is a crime and subjects such person to criminal and civil penalties.

Employee Signature Date / /

Premium calculations above may differ slightly based on rounding rules and other system factors, but will not vary significantly. Every effort has been
made to match your premiums to the penny.

Anthem Blue Cross and Blue Shield is the trade name of: Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a
registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue
Cross and Blue Shield Association.

Si usted necesita ayuda en Español para entender este documento, puede solicitarlo sin ningun costo adicional llamando al número de servicio al
cliente que se encuentra en este documento.
ABCBS-9116 (05/10) Page 5 of 5
Critical Illness
Monthly Costs
$10,000 Benefit Plan
Employee + Dep Employee +
Employee Age Employee Employee + Spouse
Child(ren) Family
18-24 $3.80 $6.20 $5.77 $8.50
25-29 $4.68 $7.54 $6.65 $9.84
30-34 $5.29 $8.47 $7.26 $10.77
35-39 $6.71 $10.63 $8.69 $12.93
40-44 $9.04 $14.21 $11.02 $16.51
45-49 $13.34 $20.88 $15.31 $23.18
50-54 $18.45 $28.83 $20.43 $31.13
55-59 $25.56 $39.95 $27.53 $42.24
60-64 $36.07 $56.27 $38.04 $58.57
65-69 $48.64 $75.53 $50.61 $77.83
70-74 $65.69 $101.69 $67.66 $103.99
75-79 $89.42 $137.65 $91.39 $139.95
80-84 $106.26 $163.11 $108.23 $165.40

$20,000 Benefit Plan

Employee Age Employee Employee + Spouse Employee + Dep Employee +

Child(ren) Family
18-24 $6.51 $10.26 $9.48 $13.72
25-29 $8.18 $12.76 $11.15 $16.22
30-34 $9.34 $14.52 $12.31 $17.98
35-39 $12.16 $18.76 $15.14 $22.23
40-44 $16.72 $25.70 $19.69 $29.17
45-49 $25.19 $38.75 $28.16 $42.22
50-54 $35.33 $54.47 $38.30 $57.93
55-59 $49.42 $76.44 $52.39 $79.90
60-64 $70.28 $108.75 $73.25 $112.21
65-69 $95.20 $146.82 $98.18 $150.29
70-74 $129.17 $198.85 $132.14 $202.31
75-79 $176.50 $270.49 $179.47 $273.95
80-84 $210.12 $321.30 $213.10 $324.76

$30,000 Benefit Plan

Employee Age Employee Employee + Spouse Employee + Dep Employee +

Child(ren) Family
18-24 $9.22 $14.32 $13.19 $18.94
25-29 $11.68 $17.97 $15.65 $22.60
30-34 $13.40 $20.57 $17.37 $25.19
35-39 $17.62 $26.90 $21.59 $31.53
40-44 $24.39 $37.20 $28.36 $41.82
45-49 $37.04 $56.63 $41.01 $61.26
50-54 $52.20 $80.10 $56.17 $84.73
55-59 $73.27 $112.93 $77.24 $117.56
60-64 $104.49 $161.24 $108.46 $165.86
65-69 $141.77 $218.12 $145.74 $222.75
70-74 $192.65 $296.00 $196.62 $300.63
75-79 $263.58 $403.32 $267.55 $407.95
80-84 $313.99 $479.50 $317.96 $484.12

1 Not available in all states. Insured will only be able to continue coverage while the policy is in-force with the policyholder and the insured must pay premium if electing to continue coverage after leaving employer.
2 Covered accidents or illness must occur after the effective date of coverage.

Group Critical Illness benefits provided by policy form SCI B XX18 P or state equivalent.
This is not a contract; it is a partial listing of benefits and services. All covered service are subject to the conditions, limitations, exclusions, terms and provisions of your policy. In the event of a discrepancy between
the information in this summary and the policy, your policy will prevail. If you have any questions, please contact your Human Resources/Benefits manager. If you have any questions, please contact your Human
Resources/Benefits manager.
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products u n d e r w r i t t e n by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana:
Anthem Insurance Companies, Inc. In Georgia: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas
City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits
underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products
u n d e r w r i t t e n by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew
Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City
of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites or administers PPO and indemnity policies and underwrites the out of network
benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC
underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
 EMPLOYEE SUPPLEMENTAL GROUP TERM LIFE and AD&D* PREMIUMS
MONTHLY PREMIUMS

TAV Holdings, Inc.

Monthly
ATTAINED
Rates
EMPLOYEE AMOUNTS OF INSURANCE

AGE Per $1,000 $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $110,000 $120,000 $130,000
<25 $0.106 $1.06 $2.12 $3.18 $4.24 $5.30 $6.36 $7.42 $8.48 $9.54 $10.60 $11.66 $12.72 $13.78
25 - 29 $0.127 $1.27 $2.54 $3.81 $5.08 $6.35 $7.62 $8.89 $10.16 $11.43 $12.70 $13.97 $15.24 $16.51
30 - 34 $0.148 $1.48 $2.96 $4.44 $5.92 $7.40 $8.88 $10.36 $11.84 $13.32 $14.80 $16.28 $17.76 $19.24
35 - 39 $0.173 $1.73 $3.46 $5.19 $6.92 $8.65 $10.38 $12.11 $13.84 $15.57 $17.30 $19.03 $20.76 $22.49
40 - 44 $0.209 $2.09 $4.18 $6.27 $8.36 $10.45 $12.54 $14.63 $16.72 $18.81 $20.90 $22.99 $25.08 $27.17
45 - 49 $0.357 $3.57 $7.14 $10.71 $14.28 $17.85 $21.42 $24.99 $28.56 $32.13 $35.70 $39.27 $42.84 $46.41
50 - 54 $0.591 $5.91 $11.82 $17.73 $23.64 $29.55 $35.46 $41.37 $47.28 $53.19 $59.10 $65.01 $70.92 $76.83
55 - 59 $1.073 $10.73 $21.46 $32.19 $42.92 $53.65 $64.38 $75.11 $85.84 $96.57 $107.30 $118.03 $128.76 $139.49
60 - 64 $1.388 $13.88 $27.76 $41.64 $55.52 $69.40 $83.28 $97.16 $111.04 $124.92 $138.80 $152.68 $166.56 $180.44
65 - 69 $2.115 $21.15 $42.30 $63.45 $84.60 $105.75 $126.90 $148.05 $169.20 $190.35 $211.50 $232.65 $253.80 $274.95
70 - 74 $3.159 $31.59 $63.18 $94.77 $126.36 $157.95 $189.54 $221.13 $252.72 $284.31 $315.90 $347.49 $379.08 $410.67
75+ $7.367 $73.67 $147.34 $221.01 $294.68 $368.35 $442.02 $515.69 $589.36 $663.03 $736.70 $810.37 $884.04 $957.71

Monthly
ATTAINED Rates
EMPLOYEE AMOUNTS OF INSURANCE

AGE Per $1,000 $140,000 $150,000 $160,000 $170,000 $180,000 $190,000 $200,000 $210,000 $220,000 $230,000 $240,000 $250,000 $260,000
<25 $0.106 $14.84 $15.90 $16.96 $18.02 $19.08 $20.14 $21.20 $22.26 $23.32 $24.38 $25.44 $26.50 $27.56
25 - 29 $0.127 $17.78 $19.05 $20.32 $21.59 $22.86 $24.13 $25.40 $26.67 $27.94 $29.21 $30.48 $31.75 $33.02
30 - 34 $0.148 $20.72 $22.20 $23.68 $25.16 $26.64 $28.12 $29.60 $31.08 $32.56 $34.04 $35.52 $37.00 $38.48
35 - 39 $0.173 $24.22 $25.95 $27.68 $29.41 $31.14 $32.87 $34.60 $36.33 $38.06 $39.79 $41.52 $43.25 $44.98
40 - 44 $0.209 $29.26 $31.35 $33.44 $35.53 $37.62 $39.71 $41.80 $43.89 $45.98 $48.07 $50.16 $52.25 $54.34
45 - 49 $0.357 $49.98 $53.55 $57.12 $60.69 $64.26 $67.83 $71.40 $74.97 $78.54 $82.11 $85.68 $89.25 $92.82
50 - 54 $0.591 $82.74 $88.65 $94.56 $100.47 $106.38 $112.29 $118.20 $124.11 $130.02 $135.93 $141.84 $147.75 $153.66
55 - 59 $1.073 $150.22 $160.95 $171.68 $182.41 $193.14 $203.87 $214.60 $225.33 $236.06 $246.79 $257.52 $268.25 $278.98
60 - 64 $1.388 $194.32 $208.20 $222.08 $235.96 $249.84 $263.72 $277.60 $291.48 $305.36 $319.24 $333.12 $347.00 $360.88
65 - 69 $2.115 $296.10 $317.25 $338.40 $359.55 $380.70 $401.85 $423.00 $444.15 $465.30 $486.45 $507.60 $528.75 $549.90
70 - 74 $3.159 $442.26 $473.85 $505.44 $537.03 $568.62 $600.21 $631.80 $663.39 $694.98 $726.57 $758.16 $789.75 $821.34
75+ $7.367 $1,031.38 $1,105.05 $1,178.72 $1,252.39 $1,326.06 $1,399.73 $1,473.40 $1,547.07 $1,620.74 $1,694.41 $1,768.08 $1,841.75 $1,915.42

Monthly
ATTAINED Rates
EMPLOYEE AMOUNTS OF INSURANCE

AGE Per $1,000 $270,000 $280,000 $290,000 $300,000 $310,000 $320,000 $330,000 $340,000 $350,000
<25 $0.106 $28.62 $29.68 $30.74 $31.80 $32.86 $33.92 $34.98 $36.04 $37.10
25 - 29 $0.127 $34.29 $35.56 $36.83 $38.10 $39.37 $40.64 $41.91 $43.18 $44.45
30 - 34 $0.148 $39.96 $41.44 $42.92 $44.40 $45.88 $47.36 $48.84 $50.32 $51.80
35 - 39 $0.173 $46.71 $48.44 $50.17 $51.90 $53.63 $55.36 $57.09 $58.82 $60.55
40 - 44 $0.209 $56.43 $58.52 $60.61 $62.70 $64.79 $66.88 $68.97 $71.06 $73.15
45 - 49 $0.357 $96.39 $99.96 $103.53 $107.10 $110.67 $114.24 $117.81 $121.38 $124.95
50 - 54 $0.591 $159.57 $165.48 $171.39 $177.30 $183.21 $189.12 $195.03 $200.94 $206.85
55 - 59 $1.073 $289.71 $300.44 $311.17 $321.90 $332.63 $343.36 $354.09 $364.82 $375.55
60 - 64 $1.388 $374.76 $388.64 $402.52 $416.40 $430.28 $444.16 $458.04 $471.92 $485.80
65 - 69 $2.115 $571.05 $592.20 $613.35 $634.50 $655.65 $676.80 $697.95 $719.10 $740.25
70 - 74 $3.159 $852.93 $884.52 $916.11 $947.70 $979.29 $1,010.88 $1,042.47 $1,074.06 $1,105.65
75+ $7.367 $1,989.09 $2,062.76 $2,136.43 $2,210.10 $2,283.77 $2,357.44 $2,431.11 $2,504.78 $2,578.45

*AD & D is offered to employee only and is included in the rates above
Spouse rates are based on Employee's age.
Rates are in five year age bands and change as you age into a new bracket.
Actual deductions may vary slightly due to rounding.
 SPOUSE SUPPLEMENTAL GROUP TERM LIFE PREMIUMS
MONTHLY PREMIUMS
TAV Holdings, Inc.
EMPLOYEE

ATTAINED Monthly Rates SPOUSE AMOUNTS OF INSURANCE

AGE Per $1,000 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 $55,000 $60,000
<25 $0.080 $0.40 $0.80 $1.20 $1.60 $2.00 $2.40 $2.80 $3.20 $3.60 $4.00 $4.40 $4.80
25 - 29 $0.101 $0.51 $1.01 $1.52 $2.02 $2.53 $3.03 $3.54 $4.04 $4.55 $5.05 $5.56 $6.06
30 - 34 $0.122 $0.61 $1.22 $1.83 $2.44 $3.05 $3.66 $4.27 $4.88 $5.49 $6.10 $6.71 $7.32
35 - 39 $0.147 $0.74 $1.47 $2.21 $2.94 $3.68 $4.41 $5.15 $5.88 $6.62 $7.35 $8.09 $8.82
40 - 44 $0.183 $0.92 $1.83 $2.75 $3.66 $4.58 $5.49 $6.41 $7.32 $8.24 $9.15 $10.07 $10.98
45 - 49 $0.331 $1.66 $3.31 $4.97 $6.62 $8.28 $9.93 $11.59 $13.24 $14.90 $16.55 $18.21 $19.86
50 - 54 $0.565 $2.83 $5.65 $8.48 $11.30 $14.13 $16.95 $19.78 $22.60 $25.43 $28.25 $31.08 $33.90
55 - 59 $1.047 $5.24 $10.47 $15.71 $20.94 $26.18 $31.41 $36.65 $41.88 $47.12 $52.35 $57.59 $62.82
60 - 64 $1.362 $6.81 $13.62 $20.43 $27.24 $34.05 $40.86 $47.67 $54.48 $61.29 $68.10 $74.91 $81.72
65 - 69 $2.089 $10.45 $20.89 $31.34 $41.78 $52.23 $62.67 $73.12 $83.56 $94.01 $104.45 $114.90 $125.34
70 - 74 $3.133 $15.67 $31.33 $47.00 $62.66 $78.33 $93.99 $109.66 $125.32 $140.99 $156.65 $172.32 $187.98
75+ $7.341 $36.71 $73.41 $110.12 $146.82 $183.53 $220.23 $256.94 $293.64 $330.35 $367.05 $403.76 $440.46

Monthly Rates SPOUSE AMOUNTS OF INSURANCE

ATTAINED
AGE Per $1,000 $65,000 $70,000 $75,000 $80,000 $85,000 $90,000 $95,000 $100,000 $105,000 $110,000 $115,000 $120,000
<25 $0.080 $5.20 $5.60 $6.00 $6.40 $6.80 $7.20 $7.60 $8.00 $8.40 $8.80 $9.20 $9.60
25 - 29 $0.101 $6.57 $7.07 $7.58 $8.08 $8.59 $9.09 $9.60 $10.10 $10.61 $11.11 $11.62 $12.12
30 - 34 $0.122 $7.93 $8.54 $9.15 $9.76 $10.37 $10.98 $11.59 $12.20 $12.81 $13.42 $14.03 $14.64
35 - 39 $0.147 $9.56 $10.29 $11.03 $11.76 $12.50 $13.23 $13.97 $14.70 $15.44 $16.17 $16.91 $17.64
40 - 44 $0.183 $11.90 $12.81 $13.73 $14.64 $15.56 $16.47 $17.39 $18.30 $19.22 $20.13 $21.05 $21.96
45 - 49 $0.331 $21.52 $23.17 $24.83 $26.48 $28.14 $29.79 $31.45 $33.10 $34.76 $36.41 $38.07 $39.72
50 - 54 $0.565 $36.73 $39.55 $42.38 $45.20 $48.03 $50.85 $53.68 $56.50 $59.33 $62.15 $64.98 $67.80
55 - 59 $1.047 $68.06 $73.29 $78.53 $83.76 $89.00 $94.23 $99.47 $104.70 $109.94 $115.17 $120.41 $125.64
60 - 64 $1.362 $88.53 $95.34 $102.15 $108.96 $115.77 $122.58 $129.39 $136.20 $143.01 $149.82 $156.63 $163.44
65 - 69 $2.089 $135.79 $146.23 $156.68 $167.12 $177.57 $188.01 $198.46 $208.90 $219.35 $229.79 $240.24 $250.68
70 - 74 $3.133 $203.65 $219.31 $234.98 $250.64 $266.31 $281.97 $297.64 $313.30 $328.97 $344.63 $360.30 $375.96
75+ $7.341 $477.17 $513.87 $550.58 $587.28 $623.99 $660.69 $697.40 $734.10 $770.81 $807.51 $844.22 $880.92

Monthly Rates SPOUSE AMOUNTS OF INSURANCE

ATTAINED
AGE Per $1,000 $125,000 $130,000 $135,000 $140,000 $145,000 $150,000 $155,000 $160,000 $165,000 $170,000 $175,000
<25 $0.080 $10.00 $10.40 $10.80 $11.20 $11.60 $12.00 $12.40 $12.80 $13.20 $13.60 $14.00
25 - 29 $0.101 $12.63 $13.13 $13.64 $14.14 $14.65 $15.15 $15.66 $16.16 $16.67 $17.17 $17.68
30 - 34 $0.122 $15.25 $15.86 $16.47 $17.08 $17.69 $18.30 $18.91 $19.52 $20.13 $20.74 $21.35
35 - 39 $0.147 $18.38 $19.11 $19.85 $20.58 $21.32 $22.05 $22.79 $23.52 $24.26 $24.99 $25.73
40 - 44 $0.183 $22.88 $23.79 $24.71 $25.62 $26.54 $27.45 $28.37 $29.28 $30.20 $31.11 $32.03
45 - 49 $0.331 $41.38 $43.03 $44.69 $46.34 $48.00 $49.65 $51.31 $52.96 $54.62 $56.27 $57.93
50 - 54 $0.565 $70.63 $73.45 $76.28 $79.10 $81.93 $84.75 $87.58 $90.40 $93.23 $96.05 $98.88
55 - 59 $1.047 $130.88 $136.11 $141.35 $146.58 $151.82 $157.05 $162.29 $167.52 $172.76 $177.99 $183.23
60 - 64 $1.362 $170.25 $177.06 $183.87 $190.68 $197.49 $204.30 $211.11 $217.92 $224.73 $231.54 $238.35
65 - 69 $2.089 $261.13 $271.57 $282.02 $292.46 $302.91 $313.35 $323.80 $334.24 $344.69 $355.13 $365.58
70 - 74 $3.133 $391.63 $407.29 $422.96 $438.62 $454.29 $469.95 $485.62 $501.28 $516.95 $532.61 $548.28
75+ $7.341 $917.63 $954.33 $991.04 $1,027.74 $1,064.45 $1,101.15 $1,137.86 $1,174.56 $1,211.27 $1,247.97 $1,284.68

Spouse rates are based on Employee's age. CHILD(REN) AMOUNTS OF INSURANCE

Rates are in five year age bands and change as you age into a new bracket. $5,000.00 $10,000.00
$1.04 $2.07
Actual deductions may vary slightly due to rounding.
 Voluntary Disability Premium Worksheet
TAV Holdings, Inc.
Your disability premium is calculated based on your age and salary on the effective date. Please use the worksheet below to calculate your estimated premium amount.
Your actual amount may vary slightly due to rounding. The example below is calculated based on an employee at age 33 with a salary of $30,000.

Voluntary Short Term Disability (VSTD)

Benefit Percentage: 60%
Weekly Benefit
$1,500
Maximum:

Example You:
VSTD Rate/$10
1. Enter your annual earnings $30,000 $______________ Age
of Benefit
Under 25 $0.462
2. Divide by 52 for weekly earnings. $576.92 $______________
25-29 $0.453
Multiply your weekly earnings in line 2 by: 60% 30-34 $0.408
3. This amount can be no more than benefit max of: $1,500 $346.15
$______________
35-39 $0.555
Round the amount in line 3 to the next $10. 40-44 $0.631
4. This is your weekly VSTD benefit amount.
$350 $______________
45-49 $0.691
50-54 $0.787
5. Divide weekly benefit in line 4 by 10 $35 $______________
55-59 $1.039
60-64 $1.242
6. Find your age and the corresponding rate on the table to the right $0.408 $______________
65-69 $1.377
Multiply the number in line 5 by the rate in line 6 70-74 $1.558
7. This is your monthly premium:
$14.28 $______________
Over 74 $1.558

To calculate paycheck premium:

$______________
Weekly: Multiply the amount in line 7 by 12 and then divide by 52.
Bi-Weekly: Multiply the amount in line 7 by 12 and then divide by 26.

Semi-Monthly: Multiply the amount in line 7 by 12 and then divide by 24.

Voluntary Long Term Disability (VLTD) Benefit Percentage: 60%

Monthly Benefit
$5,000
Maximum
Monthly Salary Maximum: $8,333

Example You:
VLTD Rate/$100
1. Enter your annual earnings $30,000 Age
Of Covered Payroll
$______________
To determine monthly earnings, divide annual earnings in line 1 by 12 Under 25 $0.419
2.
*This amount can be no more than: $8,333 $2,500 $______________ 25-29 $0.339
To determine your monthly VLTD benefit amount, you would multiple monthly earnings in line 2 by 30-34 $0.384
Benefit Percentage at the top of the VLTD grid. 35-39 $0.727
40-44 $1.326
3. Divide amount in line 2 by 100 25.0
$______________ 45-49 $1.427
50-54 $1.067
4. Find your age and the corresponding rate on the table to the right: $0.384
$______________ 55-59 $1.867
Multiply the number in line 3 by the rate in line 4: 60-64 $2.932
5.
This is your monthly premium. $9.60 $______________ 65-69 $1.951
70-74 $0.357
Over 74 $0.357
To calculate paycheck premium: $______________
Weekly: Multiply the amount in line 5 by 12 and then divide by 52.
Bi-Weekly: Multiply the amount in line 5 by 12 and then divide by 26.
Semi-Monthly: Multiply the amount in line 5 by 12 and then divide by 24.