Continuation Of Coverage Form For Group Life Insurance Form - Lincoln Financial Group Page 2

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BASIC LIFE AND OPTIONAL LIFE CONTINUATION
PREMIUM CALCULATION
AGE
RATES PER $1,000 OF COVERAGE
<30
0.13
30-34
0.14
35-39
0.20
40-44
0.32
45-49
0.54
50-54
0.80
55-59
1.20
60-64
1.98
65-69
3.57
70-74
5.04
75-80
10.90
To calculate your monthly premium amount, please follow these instructions:
EMPLOYEE
SPOUSE
1. List your benefit amount
$____________
$____________
2. Divide by $1,000
/$1,000
/$1,000
SUBTOTAL $____________
$____________
3. Multiply by the rate in the above table for your age X____________
X____________
MONTHLY PREMIUM
$____________
$____________
ACCIDENTAL DEATH & DISMEMBERMENT
PREMIUM CALCULATION
For Accidental Death & Dismemberment rates, use current group monthly premium.
DEPENDENT LIFE
PREMIUM CALCULATION
Dependent Life rates are $2.00 per $10,000 of coverage.
Page 2 of 2
GLM-01362
3/09

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