| Member's Age | Member | Spouse | All Children* |
| Under 40 | $11.50 | $18.00 | $25.00 |
| 40-49 | 16.00 | 19.50 | 20.50 |
| 50-59 | 19.50 | 25.00 | 18.00 |
| 60-64 | 25.50 | 25.50 | 15.50 |
| 65-69 | 33.80 | 33.80 | 15.50 |
| 70 & Over** | 48.40 | 48.40 | 8.30 |
Note: The minimum daily benefit for insureds under age 70 is $100. The maximum for those insureds is $200.
*One premium for all children regardless of how many are covered.
**Benefits in excess of $50 will be reduced to $50 on the premium due date on or after age 70.
The premium contributions shows above reflect the 2010 rates and benefit structure. New York Life may change premium contributions on any premium due date but not more than once in any twelvemonth period, or on any date on which benefits are changed. Your rate may change only if they are changed for all others in the same class of insureds under this Group Policy. For example, a class of insureds is a group of people with all the same issue age and gender. Benefit option amounts are subject to change by agreement between New York Life and the Policyholder.
*To pay premiums annually, multiply the premium by 2. To pay premiums quarterly, divide the premium by 2. Please note: A $2.00 administrative fee is added for billing modes other than annual.
** Benefits in excess of $50 will be reduced to $50 on the premium due
date on or after age 70.
| Premium Rate | # of $25 Units | Total Premium | |||
| Member | ____________ | x | ____________ | = | ____________ |
| Spouse | ____________ | x | ____________ | = | ____________ |
| All Children | ____________ | x | ____________ | = | ____________ |
| Total Premium | ____________ | x | ____________ | = | ____________ |
*To pay premiums annually, multiply the premium by 2. To pay premiums quarterly, divide the premium by 2. Please note: A $2.00 administrative fee is added for billing modes other than annual.