| Please select the appropriate age groups and corresponding member counts: |
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Age Group 1:
# of US Citizens:
# of Non-US Citizens:
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Age Group 2:
# of US Citizens:
# of Non-US Citizens:
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Age Group 3:
# of US Citizens:
# of Non-US Citizens:
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Age Group 4:
# of US Citizens:
# of Non-US Citizens:
|
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Age Group 5:
# of US Citizens:
# of Non-US Citizens:
|
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Age Group 6:
# of US Citizens:
# of Non-US Citizens:
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Age Group 7:
# of US Citizens:
# of Non-US Citizens:
|
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Age Group 8:
# of US Citizens:
# of Non-US Citizens:
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Age Group 9:
# of US Citizens:
# of Non-US Citizens:
|
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Age Group 10:
# of US Citizens:
# of Non-US Citizens:
|
| Age Group Notes: The Dep. Child rate is only available when parent (guardian) is insured under the same group plan. All other children must pay Child Alone rate. Applicants age 70 to 79 are limited to a $50,000 Policy Maximum. Applicants age 80 and over are limited to a $10,000 Policy Maximum. |
