The file's text, extracted by GovTribe without its formatting.
ATTACHMENT 1 – PRICING STRUCTURE
Transition Period (Date of award through December 31, 2015) Type of Coverage
| Transition Period |
| Not separately priced |
BASIC LIFE FOR ACTIVE EMPLOYEES
Base Year (January 1, 2016 through December 31, 2016)
| Type of Coverage |
| Biweekly Rate Per $1000 of Coverage |
Life coverage for employee (maximum coverage of $300,000)
Option Year 1 (January 1, 2017 through December 31, 2017)
| Type of Coverage |
| Biweekly Rate Per $1000 of Coverage |
Life coverage for employee (maximum coverage of $300,000)
Option Year 2 (January 1, 2018 through December 31, 2018)
| Type of Coverage |
| Biweekly Rate Per $1000 of Coverage |
Life coverage for employee (maximum coverage of $300,000)
Option Year 3 (January 1, 2019 through December 31, 2019)
| Type of Coverage |
| Biweekly Rate Per $1000 of Coverage |
Life coverage for employee (maximum coverage of $300,000)
Option Year 4 (January 1, 2020 through December 31, 2020)
| Type of Coverage |
| Biweekly Rate Per $1000 of Coverage |
Life coverage for employee (maximum coverage of $300,000)
BASIC LIFE FOR RETIREES
Base Year (January 1, 2016 through December 31, 2016)
| Type of Coverage |
| Biweekly Rate Per $1000 of Coverage |
| Life coverage for retirees |
| $________ |
Option Year 1 (January 1, 2017 through December 31, 2017)
| Type of Coverage |
| Biweekly Rate Per $1000 of Coverage |
| Life coverage for retirees |
| $________ |
Option Year 2 (January 1, 2018 through December 31, 2018)
| Type of Coverage |
| Biweekly Rate Per $1000 of Coverage |
| Life coverage for retirees |
| $________ |
Option Year 3 (January 1, 2019 through December 31, 2019)
| Type of Coverage |
| Biweekly Rate Per $1000 of Coverage |
| Life coverage for retirees |
| $________ |
Option Year 4 (January 1, 2020 through December 31, 2020)
| Type of Coverage |
| Biweekly Rate Per $1000 of Coverage |
| Life coverage for retirees |
| $________ |
OPTIONAL EMPLOYEE COVERAGE
Base Year (July 1, 2015 through December 31, 2015)
| Age Brackets |
| Biweekly Rate Per $1000 (maximum coverage $300,000) |
<35 35-39 40-44 45-49 50-54 55-59 60>
Option Year 1 (January 1, 2016 through December 31, 2016)
| Age Brackets |
| Biweekly Rate Per $1000 (maximum coverage $300,000) |
<35 35-39 40-44 45-49 50-54 55-59 60>
Option Year 2 (January 1, 2017 through December 31, 2017)
| Age Brackets |
| Biweekly Rate Per $1000 (maximum coverage $300,000) |
<35 35-39 40-44 45-49 50-54 55-59 60>
Option Year 3 (January 1, 2018 through December 31, 2018)
| Age Brackets |
| Biweekly Rate Per $1000 (maximum coverage $300,000) |
<35 35-39 40-44 45-49 50-54 55-59 60>
Option Year 4 (January 1, 2019 through December 31, 2019)
| Age Brackets |
| Biweekly Rate Per $1000 (maximum coverage $300,000) |
<35 35-39 40-44 45-49 50-54 55-59 60>
OPTIONAL SPOUSE/DOMESTIC PARTNER COVERAGE
| Age Brackets |
| Biweekly Rate Per $1000 |
<35 35-39 40-44 45-49 50-54 55-59 60>
| Age Brackets |
| Biweekly Rate Per $1000 |
<35 35-39 40-44 45-49 50-54 55-59 60>
| Age Brackets |
| Biweekly Rate Per $1000 |
<35 35-39 40-44 45-49 50-54 55-59 60>
| Age Brackets |
| Biweekly Rate Per $1000 |
<35 35-39 40-44 45-49 50-54 55-59 60>
| Age Brackets |
| Biweekly Rate Per $1000 |
<35 35-39 40-44 45-49 50-54 55-59 60>
OPTIONAL FAMILY COVERAGE
| Age Brackets |
| Biweekly Rate (per $5,000 employee and $2,500 child) |
<35 35-39 40-44 45-49 50-54 55-59 60>
| Age Brackets |
| Biweekly Rate (per $5,000 employee and $2,500 child) |
<35 35-39 40-44 45-49 50-54 55-59 60>
| Age Brackets |
| Biweekly Rate (per $5,000 employee and $2,500 child) |
<35 35-39 40-44 45-49 50-54 55-59 60>
| Age Brackets |
| Biweekly Rate (per $5,000 employee and $2,500 child) |
<35 35-39 40-44 45-49 50-54 55-59 60>
| Age Brackets |
| Biweekly Rate (per $5,000 employee and $2,500 child) |
<35 35-39 40-44 45-49 50-54 55-59 60>
ANNUAL PRICE ESTIMATES
Base Year: January 1, 2016 – December 31, 2016
| Type of Coverage |
| Estimated Annual Price |
| Retiree Basic Life (excluding AD&D) |
| $ ________________ |
| Employee Basic Life (including AD&D) |
| $ ________________ |
| Employee Optional Life |
| $ ________________ |
| Spousal Optional Life |
| $ ________________ |
| Optional Family Life |
| $ ________________ |
| Total Estimated Price |
| $ ________________ |
Option Year 1: January 1, 2017 – December 31, 2017
| Type of Coverage |
| Estimated Annual Price |
| Employee Basic Life (including AD&D) |
| $ ________________ |
| Retiree Basic Life (excluding AD&D) |
| $ ________________ |
| Employee Optional Life |
| $ ________________ |
| Spousal Optional Life |
| $ ________________ |
| Optional Family Life |
| $ ________________ |
| Total Estimated Price |
| $ ________________ |
Option Year 2: January 1, 2018 – December 31, 2018
| Type of Coverage |
| Estimated Annual Price |
| Employee Basic Life (including AD&D) |
| $ ________________ |
| Retiree Basic Life (excluding AD&D) |
| $ ________________ |
| Employee Optional Life |
| $ ________________ |
| Spousal Optional Life |
| $ ________________ |
| Optional Family Life |
| $ ________________ |
| Total Estimated Price |
| $ ________________ |
Option Year 3: January 1, 2019 – December 31, 2019
| Type of Coverage |
| Estimated Annual Price |
| Employee Basic Life (including AD&D) |
| $ ________________ |
| Retiree Basic Life (excluding AD&D) |
| $ ________________ |
| Employee Optional Life |
| $ ________________ |
| Spousal Optional Life |
| $ ________________ |
| Optional Family Life |
| $ ________________ |
| Total Estimated Price |
| $ ________________ |
Option Year 4: January 1, 2020 – December 31, 2020
| Type of Coverage |
| Estimated Annual Price |
| Employee Basic Life (including AD&D) |
| $ ________________ |
| Retiree Basic Life (excluding AD&D) |
| $ ________________ |
| Employee Optional Life |
| $ ________________ |
| Spousal Optional Life |
| $ ________________ |
| Optional Family Life |
| $ ________________ |
| Total Estimated Price |
| $ ________________ |
