Short Term & Long Term Disability Income Protection Insurance Enrollment Form Page 2
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1
2STD
LTD
Age Band*
.52
.28
< 25
.54
.31
25 – 29
.56
.33
30 – 34
.63
.43
35 – 39
.81
.56
40 – 44
.96
.74
45 – 49
1.12
1.07
50 – 54
1.51
1.27
55 – 59
1.93
1.39
60 – 64
2.21
1.56
65 – 69
2.21
2.20
70+
st
*Your age as of the next July 1
To calculate your per-paycheck cost for the STD coverage, complete the calculation below:
Annual Salary ________ 52 = Weekly Salary $________ x 60 % = $ ________ Weekly Benefit
Weekly Benefit $ ________ 10 = $_______ X Rate ______ = $ ________ Monthly Cost
Monthly Cost $ ________ X 12 = Annual Cost $_______ ____# of Paycycles = ________ Cost Per Pay Period**
To calculate your per-paycheck cost for the LTD coverage, complete the calculation below:
Annual Salary ________ 100 = ________ x ________ (Rate) = Your Annual Cost ($) ________
Your Annual Cost ($) ________ ________ (# of Paycycles per Year) = ($) ________ Cost Per Pay Period **
For example, if you were 45 years old, earned $45,000 annually, and were paid in 26 paycycles per year, your
calculation would be:
$45,000 (Annual Salary) 52 = 865.38 x 60% = $519.23 Your Weekly Benefit
STD:
$519.23 (Your Weekly Benefit) 10 = $51.92 X .96 (Rate) = $49.85 Monthly Cost
$49.85 (Monthly Cost) X 12 = $598.20 (Annual Cost) 26 (# of paycycles) = $23.01 per Pay Period**
$45,000 (Annual Salary) 100 = 450 x .74 (Rate) = $333.00 (Your Annual Cost)
LTD:
$333.00 26 (# of Paycycles Per Year) = $12.81 Per Pay Period**
** Final cost may vary slightly due to rounding differences. Your premium is based on your current salary and will increase as your
salary increases.
NS-6402 -2003
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