Outline of Medicare Supplement Coverage

34726CA N7-19 Rev. 3-2020

Outline of Medicare Supplement Coverage

Benefit Chart of Medicare Supplement Plans sold on or after January 1, 2020 Medicare supplement insurance can be sold in only standard plans. This chart shows the benefits included in each plan. Every insurance company must offer Plan A. Only applicants first eligible for Medicare before 2020 may purchase Plans C, F, and high deductible F.

The BASIC BENEFITS included in ALL plans are: Hospitalization: Medicare Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. Medical expenses: Medicare Part B coinsurance (usually 20 percent of the Medicare-approved amount) or copayments for hospital

outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance copayments.

Blood: First three pints of blood each year. Hospice: Part A coinsurance.

Benefits

Plans Available to All Applicants Note: A ✓ means 100% of the benefit is paid.

Shaded plans are offered by Thrivent

Medicare first eligible

before 2020 only

A B D G G1 K L M N C F F1

Medicare Part A coinsurance and hospital

coverage (up to an additional 365 days after Medicare benefits are used up)

✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Medicare Part B coinsurance or copayment ✓ ✓ ✓ ✓ 50% 75% ✓ ✓

copays apply3 ✓ ✓

Blood (first three pints) ✓ ✓ ✓ ✓ 50% 75% ✓ ✓ ✓ ✓

Part A hospice care coinsurance or copayment ✓ ✓ ✓ ✓ 50% 75% ✓ ✓ ✓ ✓

Skilled nursing facility coinsurance ✓ ✓ 50% 75% ✓ ✓ ✓ ✓

Medicare Part A deductible ✓ ✓ ✓ 50% 75% 50% ✓ ✓ ✓

Medicare Part B deductible ✓ ✓

Medicare Part B excess charges ✓ ✓

Foreign travel emergency (up to plan limits) ✓ ✓ ✓ ✓ ✓ ✓

Out-of-pocket limit in [2020]2 $[5880]2 $[2940]2 1Plans F and G also have a high deductible option which require first paying a plan deductible of $[2340] before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B deductible. However, high deductible plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible. 2Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit. 3Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that do not result in an inpatient admission.

THIS POLICY DOES NOT COVER CUSTODIAL CARE IN A SKILLED NURSING CARE FACILITY.

34726CA N7-19 Rev. 3-2020

PREMIUMS

The following page(s) display the dollar amount of annual premiums. To determine the monthly or quarterly

premium, complete the following calculations using the corresponding annual premium shown.

To calculate the monthly premium: Multiply the annual premium amount shown on the chart by .0855.

Example: $1,500.00 x .0855 = $128.25

To calculate the quarterly premium: Multiply the annual premium amount shown on the chart by .255, then add $0.75.

Example: ($1,500.00 x .255) + $0.75 = $383.25

34726CA N7-19 Rev. 3-2020

ZIP 900-908, 910-912 – Non-Smoker – Attained Age Chart shows $ amount for annual premium.

Age Plan A Plan B Plan C^ Plan D Plan F^ Plan FH^ Plan G Plan L Plan M

<64 3,156.00 3,386.40 4,722.00 4,250.40 5,041.20 784.80 4,179.60 3,129.60 3,765.60 64 2,119.20 2,026.80 2,509.20 2,127.60 2,680.80 358.80 2,094.00 1,556.40 1,948.80 65 2,119.20 2,026.80 2,509.20 2,127.60 2,680.80 358.80 2,094.00 1,556.40 1,948.80 66 2,178.00 2,064.00 2,575.20 2,191.20 2,754.00 370.80 2,160.00 1,604.40 2,007.60 67 2,239.20 2,144.40 2,648.40 2,260.80 2,829.60 384.00 2,223.60 1,657.20 2,068.80 68 2,334.00 2,240.40 2,755.20 2,364.00 2,944.80 402.00 2,324.40 1,732.80 2,161.20 69 2,428.80 2,336.40 2,863.20 2,464.80 3,060.00 420.00 2,427.60 1,809.60 2,254.80 70 2,518.80 2,433.60 2,970.00 2,571.60 3,175.20 440.40 2,530.80 1,886.40 2,347.20 71 2,608.80 2,527.20 3,081.60 2,676.00 3,291.60 460.80 2,635.20 1,965.60 2,440.80 72 2,692.80 2,617.20 3,189.60 2,779.20 3,410.40 481.20 2,737.20 2,038.80 2,535.60 73 2,767.20 2,706.00 3,303.60 2,887.20 3,532.80 500.40 2,842.80 2,119.20 2,629.20 74 2,835.60 2,790.00 3,415.20 2,998.80 3,651.60 524.40 2,950.80 2,198.40 2,725.20 75 2,895.60 2,870.40 3,530.40 3,108.00 3,771.60 544.80 3,056.40 2,281.20 2,821.20 76 2,950.80 2,944.80 3,650.40 3,222.00 3,898.80 566.40 3,171.60 2,362.80 2,917.20 77 2,994.00 3,013.20 3,768.00 3,337.20 4,024.80 589.20 3,284.40 2,450.40 3,014.40 78 3,033.60 3,074.40 3,891.60 3,451.20 4,158.00 613.20 3,399.60 2,536.80 3,115.20 79 3,066.00 3,132.00 4,014.00 3,571.20 4,287.60 637.20 3,514.80 2,622.00 3,211.20 80 3,091.20 3,184.80 4,138.80 3,690.00 4,420.80 662.40 3,633.60 2,710.80 3,312.00 81 3,109.20 3,231.60 4,260.00 3,805.20 4,554.00 687.60 3,746.40 2,800.80 3,406.80 82 3,123.60 3,276.00 4,382.40 3,925.20 4,680.00 712.80 3,862.80 2,888.40 3,502.80 83 3,139.20 3,313.20 4,501.20 4,039.20 4,808.40 736.80 3,973.20 2,972.40 3,594.00 84 3,148.80 3,351.60 4,614.00 4,146.00 4,928.40 762.00 4,081.20 3,051.60 3,682.80 85 3,156.00 3,386.40 4,722.00 4,250.40 5,041.20 784.80 4,179.60 3,129.60 3,765.60 86 3,164.40 3,420.00 4,824.00 4,348.80 5,151.60 808.80 4,279.20 3,204.00 3,844.80 87 3,172.80 3,451.20 4,918.80 4,441.20 5,254.80 825.60 4,370.40 3,267.60 3,914.40 88 3,178.80 3,486.00 5,002.80 4,524.00 5,342.40 840.00 4,452.00 3,331.20 3,981.60 89 3,184.80 3,517.20 5,083.20 4,597.20 5,426.40 854.40 4,520.40 3,385.20 4,039.20 90 3,194.40 3,550.80 5,152.80 4,665.60 5,502.00 865.20 4,588.80 3,436.80 4,092.00 91 3,200.40 3,578.40 5,216.40 4,728.00 5,570.40 877.20 4,651.20 3,483.60 4,138.80 92 3,206.40 3,613.20 5,275.20 4,783.20 5,636.40 886.80 4,706.40 3,526.80 4,179.60 93 3,211.20 3,645.60 5,331.60 4,837.20 5,694.00 896.40 4,759.20 3,564.00 4,224.00 94 3,216.00 3,673.20 5,383.20 4,887.60 5,746.80 903.60 4,808.40 3,601.20 4,260.00 95 3,222.00 3,706.80 5,433.60 4,935.60 5,799.60 913.20 4,854.00 3,636.00 4,294.80 96 3,229.20 3,734.40 5,480.40 4,978.80 5,848.80 920.40 4,897.20 3,669.60 4,326.00 97 3,234.00 3,766.80 5,527.20 5,023.20 5,898.00 927.60 4,941.60 3,703.20 4,358.40 98 3,238.80 3,796.80 5,569.20 5,067.60 5,948.40 934.80 4,982.40 3,734.40 4,392.00 99 3,253.20 3,843.60 5,635.20 5,131.20 6,014.40 946.80 5,046.00 3,783.60 4,442.40

Only applicants first eligible for Medicare before January 1, 2020, may purchase Plans C, F, and high deductible F (“Plan FH”).

34726CA N7-19 Rev. 3-2020

ZIP 900-908, 910-912 – Non-Smoker – Issue Age Chart shows $ amount for annual premium.


<64 3,216.00 3,577.20 5,220.00 4,737.60 5,575.20 865.20 4,656.00 3,392.40 4,174.80 64 2,534.40 2,566.80 3,337.20 2,948.40 3,561.60 511.20 2,889.60 2,103.60 2,662.80 65 2,534.40 2,566.80 3,337.20 2,948.40 3,561.60 511.20 2,889.60 2,103.60 2,662.80 66 2,596.80 2,634.00 3,432.00 3,037.20 3,664.80 526.80 2,983.20 2,167.20 2,740.80 67 2,662.80 2,700.00 3,529.20 3,127.20 3,768.00 544.80 3,073.20 2,227.20 2,821.20 68 2,721.60 2,767.20 3,628.80 3,222.00 3,877.20 562.80 3,164.40 2,295.60 2,904.00 69 2,775.60 2,833.20 3,726.00 3,312.00 3,986.40 580.80 3,260.40 2,361.60 2,988.00 70 2,827.20 2,896.80 3,831.60 3,412.80 4,096.80 600.00 3,360.00 2,433.60 3,073.20 71 2,880.00 2,962.80 3,937.20 3,508.80 4,209.60 621.60 3,459.60 2,504.40 3,160.80 72 2,925.60 3,026.40 4,044.00 3,613.20 4,323.60 639.60 3,555.60 2,572.80 3,248.40 73 2,968.80 3,091.20 4,150.80 3,712.80 4,436.40 658.80 3,657.60 2,646.00 3,337.20 74 3,007.20 3,150.00 4,261.20 3,813.60 4,551.60 679.20 3,758.40 2,715.60 3,422.40 75 3,042.00 3,206.40 4,365.60 3,913.20 4,662.00 698.40 3,858.00 2,788.80 3,507.60 76 3,070.80 3,260.40 4,472.40 4,014.00 4,772.40 718.80 3,955.20 2,857.20 3,592.80 77 3,099.60 3,309.60 4,576.80 4,113.60 4,887.60 740.40 4,052.40 2,928.00 3,678.00 78 3,123.60 3,355.20 4,678.80 4,212.00 4,994.40 758.40 4,149.60 2,997.60 3,757.20 79 3,144.00 3,394.80 4,779.60 4,304.40 5,100.00 777.60 4,240.80 3,061.20 3,834.00 80 3,158.40 3,430.80 4,872.00 4,399.20 5,200.80 795.60 4,328.40 3,124.80 3,908.40 81 3,175.20 3,465.60 4,959.60 4,479.60 5,295.60 813.60 4,410.00 3,184.80 3,976.80 82 3,182.40 3,495.60 5,038.80 4,560.00 5,378.40 829.20 4,484.40 3,244.80 4,038.00 83 3,198.00 3,524.40 5,108.40 4,627.20 5,452.80 842.40 4,549.20 3,297.60 4,092.00 84 3,204.00 3,552.00 5,166.00 4,684.80 5,520.00 855.60 4,606.80 3,348.00 4,137.60 85 3,216.00 3,577.20 5,220.00 4,737.60 5,575.20 865.20 4,656.00 3,392.40 4,174.80 86 3,220.80 3,603.60 5,265.60 4,782.00 5,624.40 873.60 4,701.60 3,433.20 4,208.40 87 3,226.80 3,626.40 5,305.20 4,820.40 5,665.20 880.80 4,738.80 3,475.20 4,238.40 88 3,232.80 3,650.40 5,338.80 4,854.00 5,700.00 888.00 4,773.60 3,511.20 4,264.80 89 3,238.80 3,669.60 5,367.60 4,884.00 5,731.20 891.60 4,801.20 3,544.80 4,284.00 90 3,240.00 3,690.00 5,396.40 4,911.60 5,762.40 896.40 4,832.40 3,574.80 4,302.00 91 3,247.20 3,710.40 5,421.60 4,935.60 5,787.60 901.20 4,856.40 3,606.00 4,321.20 92 3,248.40 3,727.20 5,445.60 4,960.80 5,814.00 904.80 4,880.40 3,632.40 4,335.60 93 3,249.60 3,746.40 5,469.60 4,986.00 5,840.40 909.60 4,903.20 3,657.60 4,351.20 94 3,250.80 3,762.00 5,497.20 5,008.80 5,869.20 918.00 4,928.40 3,680.40 4,365.60 95 3,250.80 3,780.00 5,524.80 5,031.60 5,896.80 922.80 4,952.40 3,703.20 4,382.40 96 3,253.20 3,794.40 5,550.00 5,056.80 5,926.80 931.20 4,975.20 3,723.60 4,398.00 97 3,253.20 3,812.40 5,577.60 5,083.20 5,956.80 936.00 5,000.40 3,744.00 4,412.40 98 3,253.20 3,826.80 5,606.40 5,104.80 5,985.60 942.00 5,022.00 3,762.00 4,426.80 99 3,253.20 3,843.60 5,635.20 5,131.20 6,014.40 946.80 5,046.00 3,783.60 4,442.40


34726CA N7-19 Rev. 3-2020

ZIP 900-908, 910-912 – Smoker – Attained Age Chart shows $ amount for annual premium.


<64 3,471.60 3,724.80 5,194.80 4,675.20 5,545.20 862.80 4,597.20 3,442.80 4,142.40 64 2,331.60 2,229.60 2,760.00 2,340.00 2,948.40 394.80 2,304.00 1,712.40 2,143.20 65 2,331.60 2,229.60 2,760.00 2,340.00 2,948.40 394.80 2,304.00 1,712.40 2,143.20 66 2,396.40 2,270.40 2,833.20 2,410.80 3,030.00 408.00 2,376.00 1,765.20 2,208.00 67 2,463.60 2,359.20 2,913.60 2,486.40 3,112.80 422.40 2,445.60 1,822.80 2,275.20 68 2,568.00 2,464.80 3,031.20 2,600.40 3,238.80 442.80 2,557.20 1,905.60 2,377.20 69 2,671.20 2,570.40 3,150.00 2,710.80 3,366.00 462.00 2,670.00 1,990.80 2,480.40 70 2,770.80 2,677.20 3,267.60 2,828.40 3,493.20 484.80 2,784.00 2,074.80 2,582.40 71 2,869.20 2,780.40 3,390.00 2,943.60 3,620.40 506.40 2,899.20 2,162.40 2,684.40 72 2,961.60 2,878.80 3,508.80 3,057.60 3,751.20 529.20 3,010.80 2,242.80 2,788.80 73 3,044.40 2,977.20 3,633.60 3,176.40 3,885.60 550.80 3,127.20 2,331.60 2,892.00 74 3,118.80 3,069.60 3,757.20 3,298.80 4,016.40 577.20 3,246.00 2,418.00 2,997.60 75 3,184.80 3,157.20 3,883.20 3,418.80 4,148.40 598.80 3,362.40 2,509.20 3,103.20 76 3,246.00 3,238.80 4,015.20 3,544.80 4,288.80 622.80 3,488.40 2,599.20 3,208.80 77 3,294.00 3,314.40 4,144.80 3,670.80 4,426.80 648.00 3,613.20 2,695.20 3,315.60 78 3,337.20 3,381.60 4,280.40 3,796.80 4,574.40 674.40 3,739.20 2,790.00 3,427.20 79 3,373.20 3,445.20 4,416.00 3,928.80 4,716.00 700.80 3,866.40 2,884.80 3,532.80 80 3,400.80 3,502.80 4,552.80 4,059.60 4,862.40 728.40 3,997.20 2,982.00 3,643.20 81 3,420.00 3,554.40 4,686.00 4,185.60 5,010.00 756.00 4,120.80 3,080.40 3,747.60 82 3,435.60 3,603.60 4,820.40 4,317.60 5,148.00 783.60 4,249.20 3,177.60 3,853.20 83 3,453.60 3,644.40 4,951.20 4,443.60 5,289.60 810.00 4,370.40 3,270.00 3,954.00 84 3,463.20 3,686.40 5,076.00 4,561.20 5,421.60 838.80 4,489.20 3,356.40 4,051.20 85 3,471.60 3,724.80 5,194.80 4,675.20 5,545.20 862.80 4,597.20 3,442.80 4,142.40 86 3,481.20 3,762.00 5,306.40 4,783.20 5,666.40 889.20 4,707.60 3,524.40 4,228.80 87 3,489.60 3,796.80 5,410.80 4,885.20 5,780.40 908.40 4,807.20 3,594.00 4,305.60 88 3,496.80 3,835.20 5,503.20 4,976.40 5,876.40 924.00 4,897.20 3,664.80 4,380.00 89 3,502.80 3,868.80 5,592.00 5,056.80 5,968.80 939.60 4,972.80 3,723.60 4,443.60 90 3,513.60 3,906.00 5,667.60 5,132.40 6,052.80 951.60 5,047.20 3,780.00 4,501.20 91 3,520.80 3,936.00 5,738.40 5,200.80 6,127.20 964.80 5,116.80 3,831.60 4,552.80 92 3,526.80 3,974.40 5,803.20 5,262.00 6,200.40 975.60 5,176.80 3,879.60 4,597.20 93 3,532.80 4,010.40 5,864.40 5,320.80 6,264.00 986.40 5,235.60 3,920.40 4,646.40 94 3,537.60 4,040.40 5,922.00 5,376.00 6,321.60 993.60 5,289.60 3,961.20 4,686.00 95 3,544.80 4,077.60 5,977.20 5,428.80 6,379.20 1,004.40 5,340.00 3,999.60 4,724.40 96 3,552.00 4,107.60 6,028.80 5,476.80 6,433.20 1,012.80 5,386.80 4,036.80 4,759.20 97 3,558.00 4,143.60 6,080.40 5,526.00 6,488.40 1,020.00 5,436.00 4,074.00 4,794.00 98 3,562.80 4,176.00 6,126.00 5,574.00 6,543.60 1,028.40 5,480.40 4,107.60 4,831.20 99 3,578.40 4,227.60 6,199.20 5,644.80 6,615.60 1,041.60 5,551.20 4,161.60 4,886.40


34726CA N7-19 Rev. 3-2020

ZIP 900-908, 910-912 – Smoker – Issue Age Chart shows $ amount for annual premium.


<64 3,537.60 3,934.80 5,742.00 5,211.60 6,133.20 951.60 5,121.60 3,732.00 4,592.40 64 2,787.60 2,823.60 3,670.80 3,243.60 3,918.00 562.80 3,178.80 2,313.60 2,929.20 65 2,787.60 2,823.60 3,670.80 3,243.60 3,918.00 562.80 3,178.80 2,313.60 2,929.20 66 2,856.00 2,898.00 3,775.20 3,340.80 4,030.80 579.60 3,282.00 2,384.40 3,014.40 67 2,929.20 2,970.00 3,882.00 3,440.40 4,144.80 598.80 3,380.40 2,450.40 3,103.20 68 2,994.00 3,044.40 3,991.20 3,544.80 4,264.80 619.20 3,481.20 2,524.80 3,194.40 69 3,052.80 3,116.40 4,099.20 3,643.20 4,384.80 638.40 3,586.80 2,598.00 3,286.80 70 3,110.40 3,186.00 4,214.40 3,753.60 4,506.00 660.00 3,696.00 2,677.20 3,380.40 71 3,168.00 3,259.20 4,330.80 3,859.20 4,630.80 684.00 3,805.20 2,755.20 3,476.40 72 3,218.40 3,328.80 4,448.40 3,974.40 4,755.60 703.20 3,910.80 2,829.60 3,573.60 73 3,265.20 3,400.80 4,566.00 4,083.60 4,880.40 724.80 4,023.60 2,911.20 3,670.80 74 3,308.40 3,465.60 4,687.20 4,195.20 5,006.40 747.60 4,134.00 2,986.80 3,764.40 75 3,346.80 3,526.80 4,802.40 4,304.40 5,128.80 768.00 4,244.40 3,067.20 3,858.00 76 3,378.00 3,586.80 4,920.00 4,416.00 5,250.00 790.80 4,351.20 3,142.80 3,951.60 77 3,409.20 3,640.80 5,034.00 4,525.20 5,376.00 814.80 4,458.00 3,220.80 4,046.40 78 3,435.60 3,691.20 5,146.80 4,633.20 5,493.60 834.00 4,564.80 3,297.60 4,132.80 79 3,458.40 3,734.40 5,257.20 4,735.20 5,610.00 855.60 4,664.40 3,367.20 4,218.00 80 3,474.00 3,774.00 5,359.20 4,839.60 5,720.40 874.80 4,761.60 3,436.80 4,299.60 81 3,493.20 3,812.40 5,455.20 4,927.20 5,824.80 895.20 4,851.60 3,502.80 4,374.00 82 3,500.40 3,844.80 5,542.80 5,016.00 5,916.00 912.00 4,933.20 3,568.80 4,442.40 83 3,518.40 3,877.20 5,619.60 5,090.40 5,997.60 926.40 5,004.00 3,627.60 4,501.20 84 3,524.40 3,907.20 5,683.20 5,152.80 6,072.00 940.80 5,067.60 3,682.80 4,551.60 85 3,537.60 3,934.80 5,742.00 5,211.60 6,133.20 951.60 5,121.60 3,732.00 4,592.40 86 3,542.40 3,963.60 5,792.40 5,260.80 6,187.20 961.20 5,172.00 3,776.40 4,629.60 87 3,549.60 3,988.80 5,835.60 5,302.80 6,231.60 968.40 5,212.80 3,823.20 4,662.00 88 3,555.60 4,015.20 5,872.80 5,340.00 6,270.00 976.80 5,251.20 3,862.80 4,690.80 89 3,562.80 4,036.80 5,904.00 5,372.40 6,304.80 980.40 5,281.20 3,898.80 4,712.40 90 3,564.00 4,059.60 5,936.40 5,402.40 6,338.40 986.40 5,316.00 3,932.40 4,732.80 91 3,572.40 4,081.20 5,964.00 5,428.80 6,366.00 991.20 5,342.40 3,967.20 4,753.20 92 3,573.60 4,100.40 5,990.40 5,456.40 6,396.00 994.80 5,368.80 3,996.00 4,768.80 93 3,574.80 4,120.80 6,016.80 5,485.20 6,424.80 1,000.80 5,394.00 4,023.60 4,786.80 94 3,576.00 4,138.80 6,046.80 5,509.20 6,456.00 1,010.40 5,421.60 4,048.80 4,802.40 95 3,576.00 4,158.00 6,076.80 5,534.40 6,486.00 1,015.20 5,448.00 4,074.00 4,820.40 96 3,578.40 4,173.60 6,105.60 5,562.00 6,519.60 1,024.80 5,473.20 4,095.60 4,838.40 97 3,578.40 4,194.00 6,135.60 5,592.00 6,552.00 1,029.60 5,500.80 4,118.40 4,854.00 98 3,578.40 4,209.60 6,166.80 5,614.80 6,584.40 1,036.80 5,524.80 4,138.80 4,869.60 99 3,578.40 4,227.60 6,199.20 5,644.80 6,615.60 1,041.60 5,551.20 4,161.60 4,886.40


34726CA N7-19 Rev. 3-2020

ZIP 913-918, 926-928 – Non-Smoker – Attained Age Chart shows $ amount for annual premium.


<64 3,024.50 3,245.30 4,525.25 4,073.30 4,831.15 752.10 4,005.45 2,999.20 3,608.70 64 2,030.90 1,942.35 2,404.65 2,038.95 2,569.10 343.85 2,006.75 1,491.55 1,867.60 65 2,030.90 1,942.35 2,404.65 2,038.95 2,569.10 343.85 2,006.75 1,491.55 1,867.60 66 2,087.25 1,978.00 2,467.90 2,099.90 2,639.25 355.35 2,070.00 1,537.55 1,923.95 67 2,145.90 2,055.05 2,538.05 2,166.60 2,711.70 368.00 2,130.95 1,588.15 1,982.60 68 2,236.75 2,147.05 2,640.40 2,265.50 2,822.10 385.25 2,227.55 1,660.60 2,071.15 69 2,327.60 2,239.05 2,743.90 2,362.10 2,932.50 402.50 2,326.45 1,734.20 2,160.85 70 2,413.85 2,332.20 2,846.25 2,464.45 3,042.90 422.05 2,425.35 1,807.80 2,249.40 71 2,500.10 2,421.90 2,953.20 2,564.50 3,154.45 441.60 2,525.40 1,883.70 2,339.10 72 2,580.60 2,508.15 3,056.70 2,663.40 3,268.30 461.15 2,623.15 1,953.85 2,429.95 73 2,651.90 2,593.25 3,165.95 2,766.90 3,385.60 479.55 2,724.35 2,030.90 2,519.65 74 2,717.45 2,673.75 3,272.90 2,873.85 3,499.45 502.55 2,827.85 2,106.80 2,611.65 75 2,774.95 2,750.80 3,383.30 2,978.50 3,614.45 522.10 2,929.05 2,186.15 2,703.65 76 2,827.85 2,822.10 3,498.30 3,087.75 3,736.35 542.80 3,039.45 2,264.35 2,795.65 77 2,869.25 2,887.65 3,611.00 3,198.15 3,857.10 564.65 3,147.55 2,348.30 2,888.80 78 2,907.20 2,946.30 3,729.45 3,307.40 3,984.75 587.65 3,257.95 2,431.10 2,985.40 79 2,938.25 3,001.50 3,846.75 3,422.40 4,108.95 610.65 3,368.35 2,512.75 3,077.40 80 2,962.40 3,052.10 3,966.35 3,536.25 4,236.60 634.80 3,482.20 2,597.85 3,174.00 81 2,979.65 3,096.95 4,082.50 3,646.65 4,364.25 658.95 3,590.30 2,684.10 3,264.85 82 2,993.45 3,139.50 4,199.80 3,761.65 4,485.00 683.10 3,701.85 2,768.05 3,356.85 83 3,008.40 3,175.15 4,313.65 3,870.90 4,608.05 706.10 3,807.65 2,848.55 3,444.25 84 3,017.60 3,211.95 4,421.75 3,973.25 4,723.05 730.25 3,911.15 2,924.45 3,529.35 85 3,024.50 3,245.30 4,525.25 4,073.30 4,831.15 752.10 4,005.45 2,999.20 3,608.70 86 3,032.55 3,277.50 4,623.00 4,167.60 4,936.95 775.10 4,100.90 3,070.50 3,684.60 87 3,040.60 3,307.40 4,713.85 4,256.15 5,035.85 791.20 4,188.30 3,131.45 3,751.30 88 3,046.35 3,340.75 4,794.35 4,335.50 5,119.80 805.00 4,266.50 3,192.40 3,815.70 89 3,052.10 3,370.65 4,871.40 4,405.65 5,200.30 818.80 4,332.05 3,244.15 3,870.90 90 3,061.30 3,402.85 4,938.10 4,471.20 5,272.75 829.15 4,397.60 3,293.60 3,921.50 91 3,067.05 3,429.30 4,999.05 4,531.00 5,338.30 840.65 4,457.40 3,338.45 3,966.35 92 3,072.80 3,462.65 5,055.40 4,583.90 5,401.55 849.85 4,510.30 3,379.85 4,005.45 93 3,077.40 3,493.70 5,109.45 4,635.65 5,456.75 859.05 4,560.90 3,415.50 4,048.00 94 3,082.00 3,520.15 5,158.90 4,683.95 5,507.35 865.95 4,608.05 3,451.15 4,082.50 95 3,087.75 3,552.35 5,207.20 4,729.95 5,557.95 875.15 4,651.75 3,484.50 4,115.85 96 3,094.65 3,578.80 5,252.05 4,771.35 5,605.10 882.05 4,693.15 3,516.70 4,145.75 97 3,099.25 3,609.85 5,296.90 4,813.90 5,652.25 888.95 4,735.70 3,548.90 4,176.80 98 3,103.85 3,638.60 5,337.15 4,856.45 5,700.55 895.85 4,774.80 3,578.80 4,209.00 99 3,117.65 3,683.45 5,400.40 4,917.40 5,763.80 907.35 4,835.75 3,625.95 4,257.30


34726CA N7-19 Rev. 3-2020

ZIP 913-918, 926-928 – Non-Smoker – Issue Age Chart shows $ amount for annual premium.


<64 3,082.00 3,428.15 5,002.50 4,540.20 5,342.90 829.15 4,462.00 3,251.05 4,000.85 64 2,428.80 2,459.85 3,198.15 2,825.55 3,413.20 489.90 2,769.20 2,015.95 2,551.85 65 2,428.80 2,459.85 3,198.15 2,825.55 3,413.20 489.90 2,769.20 2,015.95 2,551.85 66 2,488.60 2,524.25 3,289.00 2,910.65 3,512.10 504.85 2,858.90 2,076.90 2,626.60 67 2,551.85 2,587.50 3,382.15 2,996.90 3,611.00 522.10 2,945.15 2,134.40 2,703.65 68 2,608.20 2,651.90 3,477.60 3,087.75 3,715.65 539.35 3,032.55 2,199.95 2,783.00 69 2,659.95 2,715.15 3,570.75 3,174.00 3,820.30 556.60 3,124.55 2,263.20 2,863.50 70 2,709.40 2,776.10 3,671.95 3,270.60 3,926.10 575.00 3,220.00 2,332.20 2,945.15 71 2,760.00 2,839.35 3,773.15 3,362.60 4,034.20 595.70 3,315.45 2,400.05 3,029.10 72 2,803.70 2,900.30 3,875.50 3,462.65 4,143.45 612.95 3,407.45 2,465.60 3,113.05 73 2,845.10 2,962.40 3,977.85 3,558.10 4,251.55 631.35 3,505.20 2,535.75 3,198.15 74 2,881.90 3,018.75 4,083.65 3,654.70 4,361.95 650.90 3,601.80 2,602.45 3,279.80 75 2,915.25 3,072.80 4,183.70 3,750.15 4,467.75 669.30 3,697.25 2,672.60 3,361.45 76 2,942.85 3,124.55 4,286.05 3,846.75 4,573.55 688.85 3,790.40 2,738.15 3,443.10 77 2,970.45 3,171.70 4,386.10 3,942.20 4,683.95 709.55 3,883.55 2,806.00 3,524.75 78 2,993.45 3,215.40 4,483.85 4,036.50 4,786.30 726.80 3,976.70 2,872.70 3,600.65 79 3,013.00 3,253.35 4,580.45 4,125.05 4,887.50 745.20 4,064.10 2,933.65 3,674.25 80 3,026.80 3,287.85 4,669.00 4,215.90 4,984.10 762.45 4,148.05 2,994.60 3,745.55 81 3,042.90 3,321.20 4,752.95 4,292.95 5,074.95 779.70 4,226.25 3,052.10 3,811.10 82 3,049.80 3,349.95 4,828.85 4,370.00 5,154.30 794.65 4,297.55 3,109.60 3,869.75 83 3,064.75 3,377.55 4,895.55 4,434.40 5,225.60 807.30 4,359.65 3,160.20 3,921.50 84 3,070.50 3,404.00 4,950.75 4,489.60 5,290.00 819.95 4,414.85 3,208.50 3,965.20 85 3,082.00 3,428.15 5,002.50 4,540.20 5,342.90 829.15 4,462.00 3,251.05 4,000.85 86 3,086.60 3,453.45 5,046.20 4,582.75 5,390.05 837.20 4,505.70 3,290.15 4,033.05 87 3,092.35 3,475.30 5,084.15 4,619.55 5,429.15 844.10 4,541.35 3,330.40 4,061.80 88 3,098.10 3,498.30 5,116.35 4,651.75 5,462.50 851.00 4,574.70 3,364.90 4,087.10 89 3,103.85 3,516.70 5,143.95 4,680.50 5,492.40 854.45 4,601.15 3,397.10 4,105.50 90 3,105.00 3,536.25 5,171.55 4,706.95 5,522.30 859.05 4,631.05 3,425.85 4,122.75 91 3,111.90 3,555.80 5,195.70 4,729.95 5,546.45 863.65 4,654.05 3,455.75 4,141.15 92 3,113.05 3,571.90 5,218.70 4,754.10 5,571.75 867.10 4,677.05 3,481.05 4,154.95 93 3,114.20 3,590.30 5,241.70 4,778.25 5,597.05 871.70 4,698.90 3,505.20 4,169.90 94 3,115.35 3,605.25 5,268.15 4,800.10 5,624.65 879.75 4,723.05 3,527.05 4,183.70 95 3,115.35 3,622.50 5,294.60 4,821.95 5,651.10 884.35 4,746.05 3,548.90 4,199.80 96 3,117.65 3,636.30 5,318.75 4,846.10 5,679.85 892.40 4,767.90 3,568.45 4,214.75 97 3,117.65 3,653.55 5,345.20 4,871.40 5,708.60 897.00 4,792.05 3,588.00 4,228.55 98 3,117.65 3,667.35 5,372.80 4,892.10 5,736.20 902.75 4,812.75 3,605.25 4,242.35 99 3,117.65 3,683.45 5,400.40 4,917.40 5,763.80 907.35 4,835.75 3,625.95 4,257.30


34726CA N7-19 Rev. 3-2020

ZIP 913-918, 926-928 – Smoker – Attained Age Chart shows $ amount for annual premium.


<64 3,326.95 3,569.60 4,978.35 4,480.40 5,314.15 826.85 4,405.65 3,299.35 3,969.80 64 2,234.45 2,136.70 2,645.00 2,242.50 2,825.55 378.35 2,208.00 1,641.05 2,053.90 65 2,234.45 2,136.70 2,645.00 2,242.50 2,825.55 378.35 2,208.00 1,641.05 2,053.90 66 2,296.55 2,175.80 2,715.15 2,310.35 2,903.75 391.00 2,277.00 1,691.65 2,116.00 67 2,360.95 2,260.90 2,792.20 2,382.80 2,983.10 404.80 2,343.70 1,746.85 2,180.40 68 2,461.00 2,362.10 2,904.90 2,492.05 3,103.85 424.35 2,450.65 1,826.20 2,278.15 69 2,559.90 2,463.30 3,018.75 2,597.85 3,225.75 442.75 2,558.75 1,907.85 2,377.05 70 2,655.35 2,565.65 3,131.45 2,710.55 3,347.65 464.60 2,668.00 1,988.35 2,474.80 71 2,749.65 2,664.55 3,248.75 2,820.95 3,469.55 485.30 2,778.40 2,072.30 2,572.55 72 2,838.20 2,758.85 3,362.60 2,930.20 3,594.90 507.15 2,885.35 2,149.35 2,672.60 73 2,917.55 2,853.15 3,482.20 3,044.05 3,723.70 527.85 2,996.90 2,234.45 2,771.50 74 2,988.85 2,941.70 3,600.65 3,161.35 3,849.05 553.15 3,110.75 2,317.25 2,872.70 75 3,052.10 3,025.65 3,721.40 3,276.35 3,975.55 573.85 3,222.30 2,404.65 2,973.90 76 3,110.75 3,103.85 3,847.90 3,397.10 4,110.10 596.85 3,343.05 2,490.90 3,075.10 77 3,156.75 3,176.30 3,972.10 3,517.85 4,242.35 621.00 3,462.65 2,582.90 3,177.45 78 3,198.15 3,240.70 4,102.05 3,638.60 4,383.80 646.30 3,583.40 2,673.75 3,284.40 79 3,232.65 3,301.65 4,232.00 3,765.10 4,519.50 671.60 3,705.30 2,764.60 3,385.60 80 3,259.10 3,356.85 4,363.10 3,890.45 4,659.80 698.05 3,830.65 2,857.75 3,491.40 81 3,277.50 3,406.30 4,490.75 4,011.20 4,801.25 724.50 3,949.10 2,952.05 3,591.45 82 3,292.45 3,453.45 4,619.55 4,137.70 4,933.50 750.95 4,072.15 3,045.20 3,692.65 83 3,309.70 3,492.55 4,744.90 4,258.45 5,069.20 776.25 4,188.30 3,133.75 3,789.25 84 3,318.90 3,532.80 4,864.50 4,371.15 5,195.70 803.85 4,302.15 3,216.55 3,882.40 85 3,326.95 3,569.60 4,978.35 4,480.40 5,314.15 826.85 4,405.65 3,299.35 3,969.80 86 3,336.15 3,605.25 5,085.30 4,583.90 5,430.30 852.15 4,511.45 3,377.55 4,052.60 87 3,344.20 3,638.60 5,185.35 4,681.65 5,539.55 870.55 4,606.90 3,444.25 4,126.20 88 3,351.10 3,675.40 5,273.90 4,769.05 5,631.55 885.50 4,693.15 3,512.10 4,197.50 89 3,356.85 3,707.60 5,359.00 4,846.10 5,720.10 900.45 4,765.60 3,568.45 4,258.45 90 3,367.20 3,743.25 5,431.45 4,918.55 5,800.60 911.95 4,836.90 3,622.50 4,313.65 91 3,374.10 3,772.00 5,499.30 4,984.10 5,871.90 924.60 4,903.60 3,671.95 4,363.10 92 3,379.85 3,808.80 5,561.40 5,042.75 5,942.05 934.95 4,961.10 3,717.95 4,405.65 93 3,385.60 3,843.30 5,620.05 5,099.10 6,003.00 945.30 5,017.45 3,757.05 4,452.80 94 3,390.20 3,872.05 5,675.25 5,152.00 6,058.20 952.20 5,069.20 3,796.15 4,490.75 95 3,397.10 3,907.70 5,728.15 5,202.60 6,113.40 962.55 5,117.50 3,832.95 4,527.55 96 3,404.00 3,936.45 5,777.60 5,248.60 6,165.15 970.60 5,162.35 3,868.60 4,560.90 97 3,409.75 3,970.95 5,827.05 5,295.75 6,218.05 977.50 5,209.50 3,904.25 4,594.25 98 3,414.35 4,002.00 5,870.75 5,341.75 6,270.95 985.55 5,252.05 3,936.45 4,629.90 99 3,429.30 4,051.45 5,940.90 5,409.60 6,339.95 998.20 5,319.90 3,988.20 4,682.80


34726CA N7-19 Rev. 3-2020

ZIP 913-918, 926-928 – Smoker – Issue Age Chart shows $ amount for annual premium.


<64 3,390.20 3,770.85 5,502.75 4,994.45 5,877.65 911.95 4,908.20 3,576.50 4,401.05 64 2,671.45 2,705.95 3,517.85 3,108.45 3,754.75 539.35 3,046.35 2,217.20 2,807.15 65 2,671.45 2,705.95 3,517.85 3,108.45 3,754.75 539.35 3,046.35 2,217.20 2,807.15 66 2,737.00 2,777.25 3,617.90 3,201.60 3,862.85 555.45 3,145.25 2,285.05 2,888.80 67 2,807.15 2,846.25 3,720.25 3,297.05 3,972.10 573.85 3,239.55 2,348.30 2,973.90 68 2,869.25 2,917.55 3,824.90 3,397.10 4,087.10 593.40 3,336.15 2,419.60 3,061.30 69 2,925.60 2,986.55 3,928.40 3,491.40 4,202.10 611.80 3,437.35 2,489.75 3,149.85 70 2,980.80 3,053.25 4,038.80 3,597.20 4,318.25 632.50 3,542.00 2,565.65 3,239.55 71 3,036.00 3,123.40 4,150.35 3,698.40 4,437.85 655.50 3,646.65 2,640.40 3,331.55 72 3,084.30 3,190.10 4,263.05 3,808.80 4,557.45 673.90 3,747.85 2,711.70 3,424.70 73 3,129.15 3,259.10 4,375.75 3,913.45 4,677.05 694.60 3,855.95 2,789.90 3,517.85 74 3,170.55 3,321.20 4,491.90 4,020.40 4,797.80 716.45 3,961.75 2,862.35 3,607.55 75 3,207.35 3,379.85 4,602.30 4,125.05 4,915.10 736.00 4,067.55 2,939.40 3,697.25 76 3,237.25 3,437.35 4,715.00 4,232.00 5,031.25 757.85 4,169.90 3,011.85 3,786.95 77 3,267.15 3,489.10 4,824.25 4,336.65 5,152.00 780.85 4,272.25 3,086.60 3,877.80 78 3,292.45 3,537.40 4,932.35 4,440.15 5,264.70 799.25 4,374.60 3,160.20 3,960.60 79 3,314.30 3,578.80 5,038.15 4,537.90 5,376.25 819.95 4,470.05 3,226.90 4,042.25 80 3,329.25 3,616.75 5,135.90 4,637.95 5,482.05 838.35 4,563.20 3,293.60 4,120.45 81 3,347.65 3,653.55 5,227.90 4,721.90 5,582.10 857.90 4,649.45 3,356.85 4,191.75 82 3,354.55 3,684.60 5,311.85 4,807.00 5,669.50 874.00 4,727.65 3,420.10 4,257.30 83 3,371.80 3,715.65 5,385.45 4,878.30 5,747.70 887.80 4,795.50 3,476.45 4,313.65 84 3,377.55 3,744.40 5,446.40 4,938.10 5,819.00 901.60 4,856.45 3,529.35 4,361.95 85 3,390.20 3,770.85 5,502.75 4,994.45 5,877.65 911.95 4,908.20 3,576.50 4,401.05 86 3,394.80 3,798.45 5,551.05 5,041.60 5,929.40 921.15 4,956.50 3,619.05 4,436.70 87 3,401.70 3,822.60 5,592.45 5,081.85 5,971.95 928.05 4,995.60 3,663.90 4,467.75 88 3,407.45 3,847.90 5,628.10 5,117.50 6,008.75 936.10 5,032.40 3,701.85 4,495.35 89 3,414.35 3,868.60 5,658.00 5,148.55 6,042.10 939.55 5,061.15 3,736.35 4,516.05 90 3,415.50 3,890.45 5,689.05 5,177.30 6,074.30 945.30 5,094.50 3,768.55 4,535.60 91 3,423.55 3,911.15 5,715.50 5,202.60 6,100.75 949.90 5,119.80 3,801.90 4,555.15 92 3,424.70 3,929.55 5,740.80 5,229.05 6,129.50 953.35 5,145.10 3,829.50 4,570.10 93 3,425.85 3,949.10 5,766.10 5,256.65 6,157.10 959.10 5,169.25 3,855.95 4,587.35 94 3,427.00 3,966.35 5,794.85 5,279.65 6,187.00 968.30 5,195.70 3,880.10 4,602.30 95 3,427.00 3,984.75 5,823.60 5,303.80 6,215.75 972.90 5,221.00 3,904.25 4,619.55 96 3,429.30 3,999.70 5,851.20 5,330.25 6,247.95 982.10 5,245.15 3,924.95 4,636.80 97 3,429.30 4,019.25 5,879.95 5,359.00 6,279.00 986.70 5,271.60 3,946.80 4,651.75 98 3,429.30 4,034.20 5,909.85 5,380.85 6,310.05 993.60 5,294.60 3,966.35 4,666.70 99 3,429.30 4,051.45 5,940.90 5,409.60 6,339.95 998.20 5,319.90 3,988.20 4,682.80


34726CA N7-19 Rev. 3-2020

ZIP 919-921, 924-925, 930 – Non-Smoker – Attained Age Chart shows $ amount for annual premium.


<64 2,893.00 3,104.20 4,328.50 3,896.20 4,621.10 719.40 3,831.30 2,868.80 3,451.80 64 1,942.60 1,857.90 2,300.10 1,950.30 2,457.40 328.90 1,919.50 1,426.70 1,786.40 65 1,942.60 1,857.90 2,300.10 1,950.30 2,457.40 328.90 1,919.50 1,426.70 1,786.40 66 1,996.50 1,892.00 2,360.60 2,008.60 2,524.50 339.90 1,980.00 1,470.70 1,840.30 67 2,052.60 1,965.70 2,427.70 2,072.40 2,593.80 352.00 2,038.30 1,519.10 1,896.40 68 2,139.50 2,053.70 2,525.60 2,167.00 2,699.40 368.50 2,130.70 1,588.40 1,981.10 69 2,226.40 2,141.70 2,624.60 2,259.40 2,805.00 385.00 2,225.30 1,658.80 2,066.90 70 2,308.90 2,230.80 2,722.50 2,357.30 2,910.60 403.70 2,319.90 1,729.20 2,151.60 71 2,391.40 2,316.60 2,824.80 2,453.00 3,017.30 422.40 2,415.60 1,801.80 2,237.40 72 2,468.40 2,399.10 2,923.80 2,547.60 3,126.20 441.10 2,509.10 1,868.90 2,324.30 73 2,536.60 2,480.50 3,028.30 2,646.60 3,238.40 458.70 2,605.90 1,942.60 2,410.10 74 2,599.30 2,557.50 3,130.60 2,748.90 3,347.30 480.70 2,704.90 2,015.20 2,498.10 75 2,654.30 2,631.20 3,236.20 2,849.00 3,457.30 499.40 2,801.70 2,091.10 2,586.10 76 2,704.90 2,699.40 3,346.20 2,953.50 3,573.90 519.20 2,907.30 2,165.90 2,674.10 77 2,744.50 2,762.10 3,454.00 3,059.10 3,689.40 540.10 3,010.70 2,246.20 2,763.20 78 2,780.80 2,818.20 3,567.30 3,163.60 3,811.50 562.10 3,116.30 2,325.40 2,855.60 79 2,810.50 2,871.00 3,679.50 3,273.60 3,930.30 584.10 3,221.90 2,403.50 2,943.60 80 2,833.60 2,919.40 3,793.90 3,382.50 4,052.40 607.20 3,330.80 2,484.90 3,036.00 81 2,850.10 2,962.30 3,905.00 3,488.10 4,174.50 630.30 3,434.20 2,567.40 3,122.90 82 2,863.30 3,003.00 4,017.20 3,598.10 4,290.00 653.40 3,540.90 2,647.70 3,210.90 83 2,877.60 3,037.10 4,126.10 3,702.60 4,407.70 675.40 3,642.10 2,724.70 3,294.50 84 2,886.40 3,072.30 4,229.50 3,800.50 4,517.70 698.50 3,741.10 2,797.30 3,375.90 85 2,893.00 3,104.20 4,328.50 3,896.20 4,621.10 719.40 3,831.30 2,868.80 3,451.80 86 2,900.70 3,135.00 4,422.00 3,986.40 4,722.30 741.40 3,922.60 2,937.00 3,524.40 87 2,908.40 3,163.60 4,508.90 4,071.10 4,816.90 756.80 4,006.20 2,995.30 3,588.20 88 2,913.90 3,195.50 4,585.90 4,147.00 4,897.20 770.00 4,081.00 3,053.60 3,649.80 89 2,919.40 3,224.10 4,659.60 4,214.10 4,974.20 783.20 4,143.70 3,103.10 3,702.60 90 2,928.20 3,254.90 4,723.40 4,276.80 5,043.50 793.10 4,206.40 3,150.40 3,751.00 91 2,933.70 3,280.20 4,781.70 4,334.00 5,106.20 804.10 4,263.60 3,193.30 3,793.90 92 2,939.20 3,312.10 4,835.60 4,384.60 5,166.70 812.90 4,314.20 3,232.90 3,831.30 93 2,943.60 3,341.80 4,887.30 4,434.10 5,219.50 821.70 4,362.60 3,267.00 3,872.00 94 2,948.00 3,367.10 4,934.60 4,480.30 5,267.90 828.30 4,407.70 3,301.10 3,905.00 95 2,953.50 3,397.90 4,980.80 4,524.30 5,316.30 837.10 4,449.50 3,333.00 3,936.90 96 2,960.10 3,423.20 5,023.70 4,563.90 5,361.40 843.70 4,489.10 3,363.80 3,965.50 97 2,964.50 3,452.90 5,066.60 4,604.60 5,406.50 850.30 4,529.80 3,394.60 3,995.20 98 2,968.90 3,480.40 5,105.10 4,645.30 5,452.70 856.90 4,567.20 3,423.20 4,026.00 99 2,982.10 3,523.30 5,165.60 4,703.60 5,513.20 867.90 4,625.50 3,468.30 4,072.20


34726CA N7-19 Rev. 3-2020

ZIP 919-921, 924-925, 930 – Non-Smoker – Issue Age Chart shows $ amount for annual premium.


<64 2,948.00 3,279.10 4,785.00 4,342.80 5,110.60 793.10 4,268.00 3,109.70 3,826.90 64 2,323.20 2,352.90 3,059.10 2,702.70 3,264.80 468.60 2,648.80 1,928.30 2,440.90 65 2,323.20 2,352.90 3,059.10 2,702.70 3,264.80 468.60 2,648.80 1,928.30 2,440.90 66 2,380.40 2,414.50 3,146.00 2,784.10 3,359.40 482.90 2,734.60 1,986.60 2,512.40 67 2,440.90 2,475.00 3,235.10 2,866.60 3,454.00 499.40 2,817.10 2,041.60 2,586.10 68 2,494.80 2,536.60 3,326.40 2,953.50 3,554.10 515.90 2,900.70 2,104.30 2,662.00 69 2,544.30 2,597.10 3,415.50 3,036.00 3,654.20 532.40 2,988.70 2,164.80 2,739.00 70 2,591.60 2,655.40 3,512.30 3,128.40 3,755.40 550.00 3,080.00 2,230.80 2,817.10 71 2,640.00 2,715.90 3,609.10 3,216.40 3,858.80 569.80 3,171.30 2,295.70 2,897.40 72 2,681.80 2,774.20 3,707.00 3,312.10 3,963.30 586.30 3,259.30 2,358.40 2,977.70 73 2,721.40 2,833.60 3,804.90 3,403.40 4,066.70 603.90 3,352.80 2,425.50 3,059.10 74 2,756.60 2,887.50 3,906.10 3,495.80 4,172.30 622.60 3,445.20 2,489.30 3,137.20 75 2,788.50 2,939.20 4,001.80 3,587.10 4,273.50 640.20 3,536.50 2,556.40 3,215.30 76 2,814.90 2,988.70 4,099.70 3,679.50 4,374.70 658.90 3,625.60 2,619.10 3,293.40 77 2,841.30 3,033.80 4,195.40 3,770.80 4,480.30 678.70 3,714.70 2,684.00 3,371.50 78 2,863.30 3,075.60 4,288.90 3,861.00 4,578.20 695.20 3,803.80 2,747.80 3,444.10 79 2,882.00 3,111.90 4,381.30 3,945.70 4,675.00 712.80 3,887.40 2,806.10 3,514.50 80 2,895.20 3,144.90 4,466.00 4,032.60 4,767.40 729.30 3,967.70 2,864.40 3,582.70 81 2,910.60 3,176.80 4,546.30 4,106.30 4,854.30 745.80 4,042.50 2,919.40 3,645.40 82 2,917.20 3,204.30 4,618.90 4,180.00 4,930.20 760.10 4,110.70 2,974.40 3,701.50 83 2,931.50 3,230.70 4,682.70 4,241.60 4,998.40 772.20 4,170.10 3,022.80 3,751.00 84 2,937.00 3,256.00 4,735.50 4,294.40 5,060.00 784.30 4,222.90 3,069.00 3,792.80 85 2,948.00 3,279.10 4,785.00 4,342.80 5,110.60 793.10 4,268.00 3,109.70 3,826.90 86 2,952.40 3,303.30 4,826.80 4,383.50 5,155.70 800.80 4,309.80 3,147.10 3,857.70 87 2,957.90 3,324.20 4,863.10 4,418.70 5,193.10 807.40 4,343.90 3,185.60 3,885.20 88 2,963.40 3,346.20 4,893.90 4,449.50 5,225.00 814.00 4,375.80 3,218.60 3,909.40 89 2,968.90 3,363.80 4,920.30 4,477.00 5,253.60 817.30 4,401.10 3,249.40 3,927.00 90 2,970.00 3,382.50 4,946.70 4,502.30 5,282.20 821.70 4,429.70 3,276.90 3,943.50 91 2,976.60 3,401.20 4,969.80 4,524.30 5,305.30 826.10 4,451.70 3,305.50 3,961.10 92 2,977.70 3,416.60 4,991.80 4,547.40 5,329.50 829.40 4,473.70 3,329.70 3,974.30 93 2,978.80 3,434.20 5,013.80 4,570.50 5,353.70 833.80 4,494.60 3,352.80 3,988.60 94 2,979.90 3,448.50 5,039.10 4,591.40 5,380.10 841.50 4,517.70 3,373.70 4,001.80 95 2,979.90 3,465.00 5,064.40 4,612.30 5,405.40 845.90 4,539.70 3,394.60 4,017.20 96 2,982.10 3,478.20 5,087.50 4,635.40 5,432.90 853.60 4,560.60 3,413.30 4,031.50 97 2,982.10 3,494.70 5,112.80 4,659.60 5,460.40 858.00 4,583.70 3,432.00 4,044.70 98 2,982.10 3,507.90 5,139.20 4,679.40 5,486.80 863.50 4,603.50 3,448.50 4,057.90 99 2,982.10 3,523.30 5,165.60 4,703.60 5,513.20 867.90 4,625.50 3,468.30 4,072.20


34726CA N7-19 Rev. 3-2020

ZIP 919-921, 924-925, 930 – Smoker – Attained Age Chart shows $ amount for annual premium.


<64 3,182.30 3,414.40 4,761.90 4,285.60 5,083.10 790.90 4,214.10 3,155.90 3,797.20 64 2,137.30 2,043.80 2,530.00 2,145.00 2,702.70 361.90 2,112.00 1,569.70 1,964.60 65 2,137.30 2,043.80 2,530.00 2,145.00 2,702.70 361.90 2,112.00 1,569.70 1,964.60 66 2,196.70 2,081.20 2,597.10 2,209.90 2,777.50 374.00 2,178.00 1,618.10 2,024.00 67 2,258.30 2,162.60 2,670.80 2,279.20 2,853.40 387.20 2,241.80 1,670.90 2,085.60 68 2,354.00 2,259.40 2,778.60 2,383.70 2,968.90 405.90 2,344.10 1,746.80 2,179.10 69 2,448.60 2,356.20 2,887.50 2,484.90 3,085.50 423.50 2,447.50 1,824.90 2,273.70 70 2,539.90 2,454.10 2,995.30 2,592.70 3,202.10 444.40 2,552.00 1,901.90 2,367.20 71 2,630.10 2,548.70 3,107.50 2,698.30 3,318.70 464.20 2,657.60 1,982.20 2,460.70 72 2,714.80 2,638.90 3,216.40 2,802.80 3,438.60 485.10 2,759.90 2,055.90 2,556.40 73 2,790.70 2,729.10 3,330.80 2,911.70 3,561.80 504.90 2,866.60 2,137.30 2,651.00 74 2,858.90 2,813.80 3,444.10 3,023.90 3,681.70 529.10 2,975.50 2,216.50 2,747.80 75 2,919.40 2,894.10 3,559.60 3,133.90 3,802.70 548.90 3,082.20 2,300.10 2,844.60 76 2,975.50 2,968.90 3,680.60 3,249.40 3,931.40 570.90 3,197.70 2,382.60 2,941.40 77 3,019.50 3,038.20 3,799.40 3,364.90 4,057.90 594.00 3,312.10 2,470.60 3,039.30 78 3,059.10 3,099.80 3,923.70 3,480.40 4,193.20 618.20 3,427.60 2,557.50 3,141.60 79 3,092.10 3,158.10 4,048.00 3,601.40 4,323.00 642.40 3,544.20 2,644.40 3,238.40 80 3,117.40 3,210.90 4,173.40 3,721.30 4,457.20 667.70 3,664.10 2,733.50 3,339.60 81 3,135.00 3,258.20 4,295.50 3,836.80 4,592.50 693.00 3,777.40 2,823.70 3,435.30 82 3,149.30 3,303.30 4,418.70 3,957.80 4,719.00 718.30 3,895.10 2,912.80 3,532.10 83 3,165.80 3,340.70 4,538.60 4,073.30 4,848.80 742.50 4,006.20 2,997.50 3,624.50 84 3,174.60 3,379.20 4,653.00 4,181.10 4,969.80 768.90 4,115.10 3,076.70 3,713.60 85 3,182.30 3,414.40 4,761.90 4,285.60 5,083.10 790.90 4,214.10 3,155.90 3,797.20 86 3,191.10 3,448.50 4,864.20 4,384.60 5,194.20 815.10 4,315.30 3,230.70 3,876.40 87 3,198.80 3,480.40 4,959.90 4,478.10 5,298.70 832.70 4,406.60 3,294.50 3,946.80 88 3,205.40 3,515.60 5,044.60 4,561.70 5,386.70 847.00 4,489.10 3,359.40 4,015.00 89 3,210.90 3,546.40 5,126.00 4,635.40 5,471.40 861.30 4,558.40 3,413.30 4,073.30 90 3,220.80 3,580.50 5,195.30 4,704.70 5,548.40 872.30 4,626.60 3,465.00 4,126.10 91 3,227.40 3,608.00 5,260.20 4,767.40 5,616.60 884.40 4,690.40 3,512.30 4,173.40 92 3,232.90 3,643.20 5,319.60 4,823.50 5,683.70 894.30 4,745.40 3,556.30 4,214.10 93 3,238.40 3,676.20 5,375.70 4,877.40 5,742.00 904.20 4,799.30 3,593.70 4,259.20 94 3,242.80 3,703.70 5,428.50 4,928.00 5,794.80 910.80 4,848.80 3,631.10 4,295.50 95 3,249.40 3,737.80 5,479.10 4,976.40 5,847.60 920.70 4,895.00 3,666.30 4,330.70 96 3,256.00 3,765.30 5,526.40 5,020.40 5,897.10 928.40 4,937.90 3,700.40 4,362.60 97 3,261.50 3,798.30 5,573.70 5,065.50 5,947.70 935.00 4,983.00 3,734.50 4,394.50 98 3,265.90 3,828.00 5,615.50 5,109.50 5,998.30 942.70 5,023.70 3,765.30 4,428.60 99 3,280.20 3,875.30 5,682.60 5,174.40 6,064.30 954.80 5,088.60 3,814.80 4,479.20


34726CA N7-19 Rev. 3-2020

ZIP 919-921, 924-925, 930 – Smoker – Issue Age Chart shows $ amount for annual premium.


<64 3,242.80 3,606.90 5,263.50 4,777.30 5,622.10 872.30 4,694.80 3,421.00 4,209.70 64 2,555.30 2,588.30 3,364.90 2,973.30 3,591.50 515.90 2,913.90 2,120.80 2,685.10 65 2,555.30 2,588.30 3,364.90 2,973.30 3,591.50 515.90 2,913.90 2,120.80 2,685.10 66 2,618.00 2,656.50 3,460.60 3,062.40 3,694.90 531.30 3,008.50 2,185.70 2,763.20 67 2,685.10 2,722.50 3,558.50 3,153.70 3,799.40 548.90 3,098.70 2,246.20 2,844.60 68 2,744.50 2,790.70 3,658.60 3,249.40 3,909.40 567.60 3,191.10 2,314.40 2,928.20 69 2,798.40 2,856.70 3,757.60 3,339.60 4,019.40 585.20 3,287.90 2,381.50 3,012.90 70 2,851.20 2,920.50 3,863.20 3,440.80 4,130.50 605.00 3,388.00 2,454.10 3,098.70 71 2,904.00 2,987.60 3,969.90 3,537.60 4,244.90 627.00 3,488.10 2,525.60 3,186.70 72 2,950.20 3,051.40 4,077.70 3,643.20 4,359.30 644.60 3,584.90 2,593.80 3,275.80 73 2,993.10 3,117.40 4,185.50 3,743.30 4,473.70 664.40 3,688.30 2,668.60 3,364.90 74 3,032.70 3,176.80 4,296.60 3,845.60 4,589.20 685.30 3,789.50 2,737.90 3,450.70 75 3,067.90 3,232.90 4,402.20 3,945.70 4,701.40 704.00 3,890.70 2,811.60 3,536.50 76 3,096.50 3,287.90 4,510.00 4,048.00 4,812.50 724.90 3,988.60 2,880.90 3,622.30 77 3,125.10 3,337.40 4,614.50 4,148.10 4,928.00 746.90 4,086.50 2,952.40 3,709.20 78 3,149.30 3,383.60 4,717.90 4,247.10 5,035.80 764.50 4,184.40 3,022.80 3,788.40 79 3,170.20 3,423.20 4,819.10 4,340.60 5,142.50 784.30 4,275.70 3,086.60 3,866.50 80 3,184.50 3,459.50 4,912.60 4,436.30 5,243.70 801.90 4,364.80 3,150.40 3,941.30 81 3,202.10 3,494.70 5,000.60 4,516.60 5,339.40 820.60 4,447.30 3,210.90 4,009.50 82 3,208.70 3,524.40 5,080.90 4,598.00 5,423.00 836.00 4,522.10 3,271.40 4,072.20 83 3,225.20 3,554.10 5,151.30 4,666.20 5,497.80 849.20 4,587.00 3,325.30 4,126.10 84 3,230.70 3,581.60 5,209.60 4,723.40 5,566.00 862.40 4,645.30 3,375.90 4,172.30 85 3,242.80 3,606.90 5,263.50 4,777.30 5,622.10 872.30 4,694.80 3,421.00 4,209.70 86 3,247.20 3,633.30 5,309.70 4,822.40 5,671.60 881.10 4,741.00 3,461.70 4,243.80 87 3,253.80 3,656.40 5,349.30 4,860.90 5,712.30 887.70 4,778.40 3,504.60 4,273.50 88 3,259.30 3,680.60 5,383.40 4,895.00 5,747.50 895.40 4,813.60 3,540.90 4,299.90 89 3,265.90 3,700.40 5,412.00 4,924.70 5,779.40 898.70 4,841.10 3,573.90 4,319.70 90 3,267.00 3,721.30 5,441.70 4,952.20 5,810.20 904.20 4,873.00 3,604.70 4,338.40 91 3,274.70 3,741.10 5,467.00 4,976.40 5,835.50 908.60 4,897.20 3,636.60 4,357.10 92 3,275.80 3,758.70 5,491.20 5,001.70 5,863.00 911.90 4,921.40 3,663.00 4,371.40 93 3,276.90 3,777.40 5,515.40 5,028.10 5,889.40 917.40 4,944.50 3,688.30 4,387.90 94 3,278.00 3,793.90 5,542.90 5,050.10 5,918.00 926.20 4,969.80 3,711.40 4,402.20 95 3,278.00 3,811.50 5,570.40 5,073.20 5,945.50 930.60 4,994.00 3,734.50 4,418.70 96 3,280.20 3,825.80 5,596.80 5,098.50 5,976.30 939.40 5,017.10 3,754.30 4,435.20 97 3,280.20 3,844.50 5,624.30 5,126.00 6,006.00 943.80 5,042.40 3,775.20 4,449.50 98 3,280.20 3,858.80 5,652.90 5,146.90 6,035.70 950.40 5,064.40 3,793.90 4,463.80 99 3,280.20 3,875.30 5,682.60 5,174.40 6,064.30 954.80 5,088.60 3,814.80 4,479.20


34726CA N7-19 Rev. 3-2020

ZIP 922-923, 931 – Non-Smoker – Attained Age Chart shows $ amount for annual premium.


<64 2,761.50 2,963.10 4,131.75 3,719.10 4,411.05 686.70 3,657.15 2,738.40 3,294.90 64 1,854.30 1,773.45 2,195.55 1,861.65 2,345.70 313.95 1,832.25 1,361.85 1,705.20 65 1,854.30 1,773.45 2,195.55 1,861.65 2,345.70 313.95 1,832.25 1,361.85 1,705.20 66 1,905.75 1,806.00 2,253.30 1,917.30 2,409.75 324.45 1,890.00 1,403.85 1,756.65 67 1,959.30 1,876.35 2,317.35 1,978.20 2,475.90 336.00 1,945.65 1,450.05 1,810.20 68 2,042.25 1,960.35 2,410.80 2,068.50 2,576.70 351.75 2,033.85 1,516.20 1,891.05 69 2,125.20 2,044.35 2,505.30 2,156.70 2,677.50 367.50 2,124.15 1,583.40 1,972.95 70 2,203.95 2,129.40 2,598.75 2,250.15 2,778.30 385.35 2,214.45 1,650.60 2,053.80 71 2,282.70 2,211.30 2,696.40 2,341.50 2,880.15 403.20 2,305.80 1,719.90 2,135.70 72 2,356.20 2,290.05 2,790.90 2,431.80 2,984.10 421.05 2,395.05 1,783.95 2,218.65 73 2,421.30 2,367.75 2,890.65 2,526.30 3,091.20 437.85 2,487.45 1,854.30 2,300.55 74 2,481.15 2,441.25 2,988.30 2,623.95 3,195.15 458.85 2,581.95 1,923.60 2,384.55 75 2,533.65 2,511.60 3,089.10 2,719.50 3,300.15 476.70 2,674.35 1,996.05 2,468.55 76 2,581.95 2,576.70 3,194.10 2,819.25 3,411.45 495.60 2,775.15 2,067.45 2,552.55 77 2,619.75 2,636.55 3,297.00 2,920.05 3,521.70 515.55 2,873.85 2,144.10 2,637.60 78 2,654.40 2,690.10 3,405.15 3,019.80 3,638.25 536.55 2,974.65 2,219.70 2,725.80 79 2,682.75 2,740.50 3,512.25 3,124.80 3,751.65 557.55 3,075.45 2,294.25 2,809.80 80 2,704.80 2,786.70 3,621.45 3,228.75 3,868.20 579.60 3,179.40 2,371.95 2,898.00 81 2,720.55 2,827.65 3,727.50 3,329.55 3,984.75 601.65 3,278.10 2,450.70 2,980.95 82 2,733.15 2,866.50 3,834.60 3,434.55 4,095.00 623.70 3,379.95 2,527.35 3,064.95 83 2,746.80 2,899.05 3,938.55 3,534.30 4,207.35 644.70 3,476.55 2,600.85 3,144.75 84 2,755.20 2,932.65 4,037.25 3,627.75 4,312.35 666.75 3,571.05 2,670.15 3,222.45 85 2,761.50 2,963.10 4,131.75 3,719.10 4,411.05 686.70 3,657.15 2,738.40 3,294.90 86 2,768.85 2,992.50 4,221.00 3,805.20 4,507.65 707.70 3,744.30 2,803.50 3,364.20 87 2,776.20 3,019.80 4,303.95 3,886.05 4,597.95 722.40 3,824.10 2,859.15 3,425.10 88 2,781.45 3,050.25 4,377.45 3,958.50 4,674.60 735.00 3,895.50 2,914.80 3,483.90 89 2,786.70 3,077.55 4,447.80 4,022.55 4,748.10 747.60 3,955.35 2,962.05 3,534.30 90 2,795.10 3,106.95 4,508.70 4,082.40 4,814.25 757.05 4,015.20 3,007.20 3,580.50 91 2,800.35 3,131.10 4,564.35 4,137.00 4,874.10 767.55 4,069.80 3,048.15 3,621.45 92 2,805.60 3,161.55 4,615.80 4,185.30 4,931.85 775.95 4,118.10 3,085.95 3,657.15 93 2,809.80 3,189.90 4,665.15 4,232.55 4,982.25 784.35 4,164.30 3,118.50 3,696.00 94 2,814.00 3,214.05 4,710.30 4,276.65 5,028.45 790.65 4,207.35 3,151.05 3,727.50 95 2,819.25 3,243.45 4,754.40 4,318.65 5,074.65 799.05 4,247.25 3,181.50 3,757.95 96 2,825.55 3,267.60 4,795.35 4,356.45 5,117.70 805.35 4,285.05 3,210.90 3,785.25 97 2,829.75 3,295.95 4,836.30 4,395.30 5,160.75 811.65 4,323.90 3,240.30 3,813.60 98 2,833.95 3,322.20 4,873.05 4,434.15 5,204.85 817.95 4,359.60 3,267.60 3,843.00 99 2,846.55 3,363.15 4,930.80 4,489.80 5,262.60 828.45 4,415.25 3,310.65 3,887.10


34726CA N7-19 Rev. 3-2020

ZIP 922-923, 931 – Non-Smoker – Issue Age Chart shows $ amount for annual premium.


<64 2,814.00 3,130.05 4,567.50 4,145.40 4,878.30 757.05 4,074.00 2,968.35 3,652.95 64 2,217.60 2,245.95 2,920.05 2,579.85 3,116.40 447.30 2,528.40 1,840.65 2,329.95 65 2,217.60 2,245.95 2,920.05 2,579.85 3,116.40 447.30 2,528.40 1,840.65 2,329.95 66 2,272.20 2,304.75 3,003.00 2,657.55 3,206.70 460.95 2,610.30 1,896.30 2,398.20 67 2,329.95 2,362.50 3,088.05 2,736.30 3,297.00 476.70 2,689.05 1,948.80 2,468.55 68 2,381.40 2,421.30 3,175.20 2,819.25 3,392.55 492.45 2,768.85 2,008.65 2,541.00 69 2,428.65 2,479.05 3,260.25 2,898.00 3,488.10 508.20 2,852.85 2,066.40 2,614.50 70 2,473.80 2,534.70 3,352.65 2,986.20 3,584.70 525.00 2,940.00 2,129.40 2,689.05 71 2,520.00 2,592.45 3,445.05 3,070.20 3,683.40 543.90 3,027.15 2,191.35 2,765.70 72 2,559.90 2,648.10 3,538.50 3,161.55 3,783.15 559.65 3,111.15 2,251.20 2,842.35 73 2,597.70 2,704.80 3,631.95 3,248.70 3,881.85 576.45 3,200.40 2,315.25 2,920.05 74 2,631.30 2,756.25 3,728.55 3,336.90 3,982.65 594.30 3,288.60 2,376.15 2,994.60 75 2,661.75 2,805.60 3,819.90 3,424.05 4,079.25 611.10 3,375.75 2,440.20 3,069.15 76 2,686.95 2,852.85 3,913.35 3,512.25 4,175.85 628.95 3,460.80 2,500.05 3,143.70 77 2,712.15 2,895.90 4,004.70 3,599.40 4,276.65 647.85 3,545.85 2,562.00 3,218.25 78 2,733.15 2,935.80 4,093.95 3,685.50 4,370.10 663.60 3,630.90 2,622.90 3,287.55 79 2,751.00 2,970.45 4,182.15 3,766.35 4,462.50 680.40 3,710.70 2,678.55 3,354.75 80 2,763.60 3,001.95 4,263.00 3,849.30 4,550.70 696.15 3,787.35 2,734.20 3,419.85 81 2,778.30 3,032.40 4,339.65 3,919.65 4,633.65 711.90 3,858.75 2,786.70 3,479.70 82 2,784.60 3,058.65 4,408.95 3,990.00 4,706.10 725.55 3,923.85 2,839.20 3,533.25 83 2,798.25 3,083.85 4,469.85 4,048.80 4,771.20 737.10 3,980.55 2,885.40 3,580.50 84 2,803.50 3,108.00 4,520.25 4,099.20 4,830.00 748.65 4,030.95 2,929.50 3,620.40 85 2,814.00 3,130.05 4,567.50 4,145.40 4,878.30 757.05 4,074.00 2,968.35 3,652.95 86 2,818.20 3,153.15 4,607.40 4,184.25 4,921.35 764.40 4,113.90 3,004.05 3,682.35 87 2,823.45 3,173.10 4,642.05 4,217.85 4,957.05 770.70 4,146.45 3,040.80 3,708.60 88 2,828.70 3,194.10 4,671.45 4,247.25 4,987.50 777.00 4,176.90 3,072.30 3,731.70 89 2,833.95 3,210.90 4,696.65 4,273.50 5,014.80 780.15 4,201.05 3,101.70 3,748.50 90 2,835.00 3,228.75 4,721.85 4,297.65 5,042.10 784.35 4,228.35 3,127.95 3,764.25 91 2,841.30 3,246.60 4,743.90 4,318.65 5,064.15 788.55 4,249.35 3,155.25 3,781.05 92 2,842.35 3,261.30 4,764.90 4,340.70 5,087.25 791.70 4,270.35 3,178.35 3,793.65 93 2,843.40 3,278.10 4,785.90 4,362.75 5,110.35 795.90 4,290.30 3,200.40 3,807.30 94 2,844.45 3,291.75 4,810.05 4,382.70 5,135.55 803.25 4,312.35 3,220.35 3,819.90 95 2,844.45 3,307.50 4,834.20 4,402.65 5,159.70 807.45 4,333.35 3,240.30 3,834.60 96 2,846.55 3,320.10 4,856.25 4,424.70 5,185.95 814.80 4,353.30 3,258.15 3,848.25 97 2,846.55 3,335.85 4,880.40 4,447.80 5,212.20 819.00 4,375.35 3,276.00 3,860.85 98 2,846.55 3,348.45 4,905.60 4,466.70 5,237.40 824.25 4,394.25 3,291.75 3,873.45 99 2,846.55 3,363.15 4,930.80 4,489.80 5,262.60 828.45 4,415.25 3,310.65 3,887.10


34726CA N7-19 Rev. 3-2020

ZIP 922-923, 931 – Smoker – Attained Age Chart shows $ amount for annual premium.


<64 3,037.65 3,259.20 4,545.45 4,090.80 4,852.05 754.95 4,022.55 3,012.45 3,624.60

64 2,040.15 1,950.90 2,415.00 2,047.50 2,579.85 345.45 2,016.00 1,498.35 1,875.30

65 2,040.15 1,950.90 2,415.00 2,047.50 2,579.85 345.45 2,016.00 1,498.35 1,875.30

66 2,096.85 1,986.60 2,479.05 2,109.45 2,651.25 357.00 2,079.00 1,544.55 1,932.00

67 2,155.65 2,064.30 2,549.40 2,175.60 2,723.70 369.60 2,139.90 1,594.95 1,990.80

68 2,247.00 2,156.70 2,652.30 2,275.35 2,833.95 387.45 2,237.55 1,667.40 2,080.05

69 2,337.30 2,249.10 2,756.25 2,371.95 2,945.25 404.25 2,336.25 1,741.95 2,170.35

70 2,424.45 2,342.55 2,859.15 2,474.85 3,056.55 424.20 2,436.00 1,815.45 2,259.60

71 2,510.55 2,432.85 2,966.25 2,575.65 3,167.85 443.10 2,536.80 1,892.10 2,348.85

72 2,591.40 2,518.95 3,070.20 2,675.40 3,282.30 463.05 2,634.45 1,962.45 2,440.20

73 2,663.85 2,605.05 3,179.40 2,779.35 3,399.90 481.95 2,736.30 2,040.15 2,530.50

74 2,728.95 2,685.90 3,287.55 2,886.45 3,514.35 505.05 2,840.25 2,115.75 2,622.90

75 2,786.70 2,762.55 3,397.80 2,991.45 3,629.85 523.95 2,942.10 2,195.55 2,715.30

76 2,840.25 2,833.95 3,513.30 3,101.70 3,752.70 544.95 3,052.35 2,274.30 2,807.70

77 2,882.25 2,900.10 3,626.70 3,211.95 3,873.45 567.00 3,161.55 2,358.30 2,901.15

78 2,920.05 2,958.90 3,745.35 3,322.20 4,002.60 590.10 3,271.80 2,441.25 2,998.80

79 2,951.55 3,014.55 3,864.00 3,437.70 4,126.50 613.20 3,383.10 2,524.20 3,091.20

80 2,975.70 3,064.95 3,983.70 3,552.15 4,254.60 637.35 3,497.55 2,609.25 3,187.80

81 2,992.50 3,110.10 4,100.25 3,662.40 4,383.75 661.50 3,605.70 2,695.35 3,279.15

82 3,006.15 3,153.15 4,217.85 3,777.90 4,504.50 685.65 3,718.05 2,780.40 3,371.55

83 3,021.90 3,188.85 4,332.30 3,888.15 4,628.40 708.75 3,824.10 2,861.25 3,459.75

84 3,030.30 3,225.60 4,441.50 3,991.05 4,743.90 733.95 3,928.05 2,936.85 3,544.80

85 3,037.65 3,259.20 4,545.45 4,090.80 4,852.05 754.95 4,022.55 3,012.45 3,624.60

86 3,046.05 3,291.75 4,643.10 4,185.30 4,958.10 778.05 4,119.15 3,083.85 3,700.20

87 3,053.40 3,322.20 4,734.45 4,274.55 5,057.85 794.85 4,206.30 3,144.75 3,767.40

88 3,059.70 3,355.80 4,815.30 4,354.35 5,141.85 808.50 4,285.05 3,206.70 3,832.50

89 3,064.95 3,385.20 4,893.00 4,424.70 5,222.70 822.15 4,351.20 3,258.15 3,888.15

90 3,074.40 3,417.75 4,959.15 4,490.85 5,296.20 832.65 4,416.30 3,307.50 3,938.55

91 3,080.70 3,444.00 5,021.10 4,550.70 5,361.30 844.20 4,477.20 3,352.65 3,983.70

92 3,085.95 3,477.60 5,077.80 4,604.25 5,425.35 853.65 4,529.70 3,394.65 4,022.55

93 3,091.20 3,509.10 5,131.35 4,655.70 5,481.00 863.10 4,581.15 3,430.35 4,065.60

94 3,095.40 3,535.35 5,181.75 4,704.00 5,531.40 869.40 4,628.40 3,466.05 4,100.25

95 3,101.70 3,567.90 5,230.05 4,750.20 5,581.80 878.85 4,672.50 3,499.65 4,133.85

96 3,108.00 3,594.15 5,275.20 4,792.20 5,629.05 886.20 4,713.45 3,532.20 4,164.30

97 3,113.25 3,625.65 5,320.35 4,835.25 5,677.35 892.50 4,756.50 3,564.75 4,194.75

98 3,117.45 3,654.00 5,360.25 4,877.25 5,725.65 899.85 4,795.35 3,594.15 4,227.30

99 3,131.10 3,699.15 5,424.30 4,939.20 5,788.65 911.40 4,857.30 3,641.40 4,275.60


34726CA N7-19 Rev. 3-2020

ZIP 922-923, 931 – Smoker – Issue Age Chart shows $ amount for annual premium.


<64 3,095.40 3,442.95 5,024.25 4,560.15 5,366.55 832.65 4,481.40 3,265.50 4,018.35 64 2,439.15 2,470.65 3,211.95 2,838.15 3,428.25 492.45 2,781.45 2,024.40 2,563.05 65 2,439.15 2,470.65 3,211.95 2,838.15 3,428.25 492.45 2,781.45 2,024.40 2,563.05 66 2,499.00 2,535.75 3,303.30 2,923.20 3,526.95 507.15 2,871.75 2,086.35 2,637.60 67 2,563.05 2,598.75 3,396.75 3,010.35 3,626.70 523.95 2,957.85 2,144.10 2,715.30 68 2,619.75 2,663.85 3,492.30 3,101.70 3,731.70 541.80 3,046.05 2,209.20 2,795.10 69 2,671.20 2,726.85 3,586.80 3,187.80 3,836.70 558.60 3,138.45 2,273.25 2,875.95 70 2,721.60 2,787.75 3,687.60 3,284.40 3,942.75 577.50 3,234.00 2,342.55 2,957.85 71 2,772.00 2,851.80 3,789.45 3,376.80 4,051.95 598.50 3,329.55 2,410.80 3,041.85 72 2,816.10 2,912.70 3,892.35 3,477.60 4,161.15 615.30 3,421.95 2,475.90 3,126.90 73 2,857.05 2,975.70 3,995.25 3,573.15 4,270.35 634.20 3,520.65 2,547.30 3,211.95 74 2,894.85 3,032.40 4,101.30 3,670.80 4,380.60 654.15 3,617.25 2,613.45 3,293.85 75 2,928.45 3,085.95 4,202.10 3,766.35 4,487.70 672.00 3,713.85 2,683.80 3,375.75 76 2,955.75 3,138.45 4,305.00 3,864.00 4,593.75 691.95 3,807.30 2,749.95 3,457.65 77 2,983.05 3,185.70 4,404.75 3,959.55 4,704.00 712.95 3,900.75 2,818.20 3,540.60 78 3,006.15 3,229.80 4,503.45 4,054.05 4,806.90 729.75 3,994.20 2,885.40 3,616.20 79 3,026.10 3,267.60 4,600.05 4,143.30 4,908.75 748.65 4,081.35 2,946.30 3,690.75 80 3,039.75 3,302.25 4,689.30 4,234.65 5,005.35 765.45 4,166.40 3,007.20 3,762.15 81 3,056.55 3,335.85 4,773.30 4,311.30 5,096.70 783.30 4,245.15 3,064.95 3,827.25 82 3,062.85 3,364.20 4,849.95 4,389.00 5,176.50 798.00 4,316.55 3,122.70 3,887.10 83 3,078.60 3,392.55 4,917.15 4,454.10 5,247.90 810.60 4,378.50 3,174.15 3,938.55 84 3,083.85 3,418.80 4,972.80 4,508.70 5,313.00 823.20 4,434.15 3,222.45 3,982.65 85 3,095.40 3,442.95 5,024.25 4,560.15 5,366.55 832.65 4,481.40 3,265.50 4,018.35 86 3,099.60 3,468.15 5,068.35 4,603.20 5,413.80 841.05 4,525.50 3,304.35 4,050.90 87 3,105.90 3,490.20 5,106.15 4,639.95 5,452.65 847.35 4,561.20 3,345.30 4,079.25 88 3,111.15 3,513.30 5,138.70 4,672.50 5,486.25 854.70 4,594.80 3,379.95 4,104.45 89 3,117.45 3,532.20 5,166.00 4,700.85 5,516.70 857.85 4,621.05 3,411.45 4,123.35 90 3,118.50 3,552.15 5,194.35 4,727.10 5,546.10 863.10 4,651.50 3,440.85 4,141.20 91 3,125.85 3,571.05 5,218.50 4,750.20 5,570.25 867.30 4,674.60 3,471.30 4,159.05 92 3,126.90 3,587.85 5,241.60 4,774.35 5,596.50 870.45 4,697.70 3,496.50 4,172.70 93 3,127.95 3,605.70 5,264.70 4,799.55 5,621.70 875.70 4,719.75 3,520.65 4,188.45 94 3,129.00 3,621.45 5,290.95 4,820.55 5,649.00 884.10 4,743.90 3,542.70 4,202.10 95 3,129.00 3,638.25 5,317.20 4,842.60 5,675.25 888.30 4,767.00 3,564.75 4,217.85 96 3,131.10 3,651.90 5,342.40 4,866.75 5,704.65 896.70 4,789.05 3,583.65 4,233.60 97 3,131.10 3,669.75 5,368.65 4,893.00 5,733.00 900.90 4,813.20 3,603.60 4,247.25 98 3,131.10 3,683.40 5,395.95 4,912.95 5,761.35 907.20 4,834.20 3,621.45 4,260.90 99 3,131.10 3,699.15 5,424.30 4,939.20 5,788.65 911.40 4,857.30 3,641.40 4,275.60


34726CA N7-19 Rev. 3-2020

ZIP 932-959 – Non-Smoker – Attained Age Chart shows $ amount for annual premium.


<64 2,630.00 2,822.00 3,935.00 3,542.00 4,201.00 654.00 3,483.00 2,608.00 3,138.00 64 1,766.00 1,689.00 2,091.00 1,773.00 2,234.00 299.00 1,745.00 1,297.00 1,624.00 65 1,766.00 1,689.00 2,091.00 1,773.00 2,234.00 299.00 1,745.00 1,297.00 1,624.00 66 1,815.00 1,720.00 2,146.00 1,826.00 2,295.00 309.00 1,800.00 1,337.00 1,673.00 67 1,866.00 1,787.00 2,207.00 1,884.00 2,358.00 320.00 1,853.00 1,381.00 1,724.00 68 1,945.00 1,867.00 2,296.00 1,970.00 2,454.00 335.00 1,937.00 1,444.00 1,801.00 69 2,024.00 1,947.00 2,386.00 2,054.00 2,550.00 350.00 2,023.00 1,508.00 1,879.00 70 2,099.00 2,028.00 2,475.00 2,143.00 2,646.00 367.00 2,109.00 1,572.00 1,956.00 71 2,174.00 2,106.00 2,568.00 2,230.00 2,743.00 384.00 2,196.00 1,638.00 2,034.00 72 2,244.00 2,181.00 2,658.00 2,316.00 2,842.00 401.00 2,281.00 1,699.00 2,113.00 73 2,306.00 2,255.00 2,753.00 2,406.00 2,944.00 417.00 2,369.00 1,766.00 2,191.00 74 2,363.00 2,325.00 2,846.00 2,499.00 3,043.00 437.00 2,459.00 1,832.00 2,271.00 75 2,413.00 2,392.00 2,942.00 2,590.00 3,143.00 454.00 2,547.00 1,901.00 2,351.00 76 2,459.00 2,454.00 3,042.00 2,685.00 3,249.00 472.00 2,643.00 1,969.00 2,431.00 77 2,495.00 2,511.00 3,140.00 2,781.00 3,354.00 491.00 2,737.00 2,042.00 2,512.00 78 2,528.00 2,562.00 3,243.00 2,876.00 3,465.00 511.00 2,833.00 2,114.00 2,596.00 79 2,555.00 2,610.00 3,345.00 2,976.00 3,573.00 531.00 2,929.00 2,185.00 2,676.00 80 2,576.00 2,654.00 3,449.00 3,075.00 3,684.00 552.00 3,028.00 2,259.00 2,760.00 81 2,591.00 2,693.00 3,550.00 3,171.00 3,795.00 573.00 3,122.00 2,334.00 2,839.00 82 2,603.00 2,730.00 3,652.00 3,271.00 3,900.00 594.00 3,219.00 2,407.00 2,919.00 83 2,616.00 2,761.00 3,751.00 3,366.00 4,007.00 614.00 3,311.00 2,477.00 2,995.00 84 2,624.00 2,793.00 3,845.00 3,455.00 4,107.00 635.00 3,401.00 2,543.00 3,069.00 85 2,630.00 2,822.00 3,935.00 3,542.00 4,201.00 654.00 3,483.00 2,608.00 3,138.00 86 2,637.00 2,850.00 4,020.00 3,624.00 4,293.00 674.00 3,566.00 2,670.00 3,204.00 87 2,644.00 2,876.00 4,099.00 3,701.00 4,379.00 688.00 3,642.00 2,723.00 3,262.00 88 2,649.00 2,905.00 4,169.00 3,770.00 4,452.00 700.00 3,710.00 2,776.00 3,318.00 89 2,654.00 2,931.00 4,236.00 3,831.00 4,522.00 712.00 3,767.00 2,821.00 3,366.00 90 2,662.00 2,959.00 4,294.00 3,888.00 4,585.00 721.00 3,824.00 2,864.00 3,410.00 91 2,667.00 2,982.00 4,347.00 3,940.00 4,642.00 731.00 3,876.00 2,903.00 3,449.00 92 2,672.00 3,011.00 4,396.00 3,986.00 4,697.00 739.00 3,922.00 2,939.00 3,483.00 93 2,676.00 3,038.00 4,443.00 4,031.00 4,745.00 747.00 3,966.00 2,970.00 3,520.00 94 2,680.00 3,061.00 4,486.00 4,073.00 4,789.00 753.00 4,007.00 3,001.00 3,550.00 95 2,685.00 3,089.00 4,528.00 4,113.00 4,833.00 761.00 4,045.00 3,030.00 3,579.00 96 2,691.00 3,112.00 4,567.00 4,149.00 4,874.00 767.00 4,081.00 3,058.00 3,605.00 97 2,695.00 3,139.00 4,606.00 4,186.00 4,915.00 773.00 4,118.00 3,086.00 3,632.00 98 2,699.00 3,164.00 4,641.00 4,223.00 4,957.00 779.00 4,152.00 3,112.00 3,660.00 99 2,711.00 3,203.00 4,696.00 4,276.00 5,012.00 789.00 4,205.00 3,153.00 3,702.00


34726CA N7-19 Rev. 3-2020

ZIP 932-959 – Non-Smoker – Issue Age Chart shows $ amount for annual premium.


<64 2,680.00 2,981.00 4,350.00 3,948.00 4,646.00 721.00 3,880.00 2,827.00 3,479.00 64 2,112.00 2,139.00 2,781.00 2,457.00 2,968.00 426.00 2,408.00 1,753.00 2,219.00 65 2,112.00 2,139.00 2,781.00 2,457.00 2,968.00 426.00 2,408.00 1,753.00 2,219.00 66 2,164.00 2,195.00 2,860.00 2,531.00 3,054.00 439.00 2,486.00 1,806.00 2,284.00 67 2,219.00 2,250.00 2,941.00 2,606.00 3,140.00 454.00 2,561.00 1,856.00 2,351.00 68 2,268.00 2,306.00 3,024.00 2,685.00 3,231.00 469.00 2,637.00 1,913.00 2,420.00 69 2,313.00 2,361.00 3,105.00 2,760.00 3,322.00 484.00 2,717.00 1,968.00 2,490.00 70 2,356.00 2,414.00 3,193.00 2,844.00 3,414.00 500.00 2,800.00 2,028.00 2,561.00 71 2,400.00 2,469.00 3,281.00 2,924.00 3,508.00 518.00 2,883.00 2,087.00 2,634.00 72 2,438.00 2,522.00 3,370.00 3,011.00 3,603.00 533.00 2,963.00 2,144.00 2,707.00 73 2,474.00 2,576.00 3,459.00 3,094.00 3,697.00 549.00 3,048.00 2,205.00 2,781.00 74 2,506.00 2,625.00 3,551.00 3,178.00 3,793.00 566.00 3,132.00 2,263.00 2,852.00 75 2,535.00 2,672.00 3,638.00 3,261.00 3,885.00 582.00 3,215.00 2,324.00 2,923.00 76 2,559.00 2,717.00 3,727.00 3,345.00 3,977.00 599.00 3,296.00 2,381.00 2,994.00 77 2,583.00 2,758.00 3,814.00 3,428.00 4,073.00 617.00 3,377.00 2,440.00 3,065.00 78 2,603.00 2,796.00 3,899.00 3,510.00 4,162.00 632.00 3,458.00 2,498.00 3,131.00 79 2,620.00 2,829.00 3,983.00 3,587.00 4,250.00 648.00 3,534.00 2,551.00 3,195.00 80 2,632.00 2,859.00 4,060.00 3,666.00 4,334.00 663.00 3,607.00 2,604.00 3,257.00 81 2,646.00 2,888.00 4,133.00 3,733.00 4,413.00 678.00 3,675.00 2,654.00 3,314.00 82 2,652.00 2,913.00 4,199.00 3,800.00 4,482.00 691.00 3,737.00 2,704.00 3,365.00 83 2,665.00 2,937.00 4,257.00 3,856.00 4,544.00 702.00 3,791.00 2,748.00 3,410.00 84 2,670.00 2,960.00 4,305.00 3,904.00 4,600.00 713.00 3,839.00 2,790.00 3,448.00 85 2,680.00 2,981.00 4,350.00 3,948.00 4,646.00 721.00 3,880.00 2,827.00 3,479.00 86 2,684.00 3,003.00 4,388.00 3,985.00 4,687.00 728.00 3,918.00 2,861.00 3,507.00 87 2,689.00 3,022.00 4,421.00 4,017.00 4,721.00 734.00 3,949.00 2,896.00 3,532.00 88 2,694.00 3,042.00 4,449.00 4,045.00 4,750.00 740.00 3,978.00 2,926.00 3,554.00 89 2,699.00 3,058.00 4,473.00 4,070.00 4,776.00 743.00 4,001.00 2,954.00 3,570.00 90 2,700.00 3,075.00 4,497.00 4,093.00 4,802.00 747.00 4,027.00 2,979.00 3,585.00 91 2,706.00 3,092.00 4,518.00 4,113.00 4,823.00 751.00 4,047.00 3,005.00 3,601.00 92 2,707.00 3,106.00 4,538.00 4,134.00 4,845.00 754.00 4,067.00 3,027.00 3,613.00 93 2,708.00 3,122.00 4,558.00 4,155.00 4,867.00 758.00 4,086.00 3,048.00 3,626.00 94 2,709.00 3,135.00 4,581.00 4,174.00 4,891.00 765.00 4,107.00 3,067.00 3,638.00 95 2,709.00 3,150.00 4,604.00 4,193.00 4,914.00 769.00 4,127.00 3,086.00 3,652.00 96 2,711.00 3,162.00 4,625.00 4,214.00 4,939.00 776.00 4,146.00 3,103.00 3,665.00 97 2,711.00 3,177.00 4,648.00 4,236.00 4,964.00 780.00 4,167.00 3,120.00 3,677.00 98 2,711.00 3,189.00 4,672.00 4,254.00 4,988.00 785.00 4,185.00 3,135.00 3,689.00 99 2,711.00 3,203.00 4,696.00 4,276.00 5,012.00 789.00 4,205.00 3,153.00 3,702.00


34726CA N7-19 Rev. 3-2020

ZIP 932-959 – Smoker – Attained Age Chart shows $ amount for annual premium.


<64 2,893.00 3,104.00 4,329.00 3,896.00 4,621.00 719.00 3,831.00 2,869.00 3,452.00 64 1,943.00 1,858.00 2,300.00 1,950.00 2,457.00 329.00 1,920.00 1,427.00 1,786.00 65 1,943.00 1,858.00 2,300.00 1,950.00 2,457.00 329.00 1,920.00 1,427.00 1,786.00 66 1,997.00 1,892.00 2,361.00 2,009.00 2,525.00 340.00 1,980.00 1,471.00 1,840.00 67 2,053.00 1,966.00 2,428.00 2,072.00 2,594.00 352.00 2,038.00 1,519.00 1,896.00 68 2,140.00 2,054.00 2,526.00 2,167.00 2,699.00 369.00 2,131.00 1,588.00 1,981.00 69 2,226.00 2,142.00 2,625.00 2,259.00 2,805.00 385.00 2,225.00 1,659.00 2,067.00 70 2,309.00 2,231.00 2,723.00 2,357.00 2,911.00 404.00 2,320.00 1,729.00 2,152.00 71 2,391.00 2,317.00 2,825.00 2,453.00 3,017.00 422.00 2,416.00 1,802.00 2,237.00 72 2,468.00 2,399.00 2,924.00 2,548.00 3,126.00 441.00 2,509.00 1,869.00 2,324.00 73 2,537.00 2,481.00 3,028.00 2,647.00 3,238.00 459.00 2,606.00 1,943.00 2,410.00 74 2,599.00 2,558.00 3,131.00 2,749.00 3,347.00 481.00 2,705.00 2,015.00 2,498.00 75 2,654.00 2,631.00 3,236.00 2,849.00 3,457.00 499.00 2,802.00 2,091.00 2,586.00 76 2,705.00 2,699.00 3,346.00 2,954.00 3,574.00 519.00 2,907.00 2,166.00 2,674.00 77 2,745.00 2,762.00 3,454.00 3,059.00 3,689.00 540.00 3,011.00 2,246.00 2,763.00 78 2,781.00 2,818.00 3,567.00 3,164.00 3,812.00 562.00 3,116.00 2,325.00 2,856.00 79 2,811.00 2,871.00 3,680.00 3,274.00 3,930.00 584.00 3,222.00 2,404.00 2,944.00 80 2,834.00 2,919.00 3,794.00 3,383.00 4,052.00 607.00 3,331.00 2,485.00 3,036.00 81 2,850.00 2,962.00 3,905.00 3,488.00 4,175.00 630.00 3,434.00 2,567.00 3,123.00 82 2,863.00 3,003.00 4,017.00 3,598.00 4,290.00 653.00 3,541.00 2,648.00 3,211.00 83 2,878.00 3,037.00 4,126.00 3,703.00 4,408.00 675.00 3,642.00 2,725.00 3,295.00 84 2,886.00 3,072.00 4,230.00 3,801.00 4,518.00 699.00 3,741.00 2,797.00 3,376.00 85 2,893.00 3,104.00 4,329.00 3,896.00 4,621.00 719.00 3,831.00 2,869.00 3,452.00 86 2,901.00 3,135.00 4,422.00 3,986.00 4,722.00 741.00 3,923.00 2,937.00 3,524.00 87 2,908.00 3,164.00 4,509.00 4,071.00 4,817.00 757.00 4,006.00 2,995.00 3,588.00 88 2,914.00 3,196.00 4,586.00 4,147.00 4,897.00 770.00 4,081.00 3,054.00 3,650.00 89 2,919.00 3,224.00 4,660.00 4,214.00 4,974.00 783.00 4,144.00 3,103.00 3,703.00 90 2,928.00 3,255.00 4,723.00 4,277.00 5,044.00 793.00 4,206.00 3,150.00 3,751.00 91 2,934.00 3,280.00 4,782.00 4,334.00 5,106.00 804.00 4,264.00 3,193.00 3,794.00 92 2,939.00 3,312.00 4,836.00 4,385.00 5,167.00 813.00 4,314.00 3,233.00 3,831.00 93 2,944.00 3,342.00 4,887.00 4,434.00 5,220.00 822.00 4,363.00 3,267.00 3,872.00 94 2,948.00 3,367.00 4,935.00 4,480.00 5,268.00 828.00 4,408.00 3,301.00 3,905.00 95 2,954.00 3,398.00 4,981.00 4,524.00 5,316.00 837.00 4,450.00 3,333.00 3,937.00 96 2,960.00 3,423.00 5,024.00 4,564.00 5,361.00 844.00 4,489.00 3,364.00 3,966.00 97 2,965.00 3,453.00 5,067.00 4,605.00 5,407.00 850.00 4,530.00 3,395.00 3,995.00 98 2,969.00 3,480.00 5,105.00 4,645.00 5,453.00 857.00 4,567.00 3,423.00 4,026.00 99 2,982.00 3,523.00 5,166.00 4,704.00 5,513.00 868.00 4,626.00 3,468.00 4,072.00


34726CA N7-19 Rev. 3-2020

ZIP 932-959 – Smoker – Issue Age Chart shows $ amount for annual premium.


<64 2,948.00 3,279.00 4,785.00 4,343.00 5,111.00 793.00 4,268.00 3,110.00 3,827.00 64 2,323.00 2,353.00 3,059.00 2,703.00 3,265.00 469.00 2,649.00 1,928.00 2,441.00 65 2,323.00 2,353.00 3,059.00 2,703.00 3,265.00 469.00 2,649.00 1,928.00 2,441.00 66 2,380.00 2,415.00 3,146.00 2,784.00 3,359.00 483.00 2,735.00 1,987.00 2,512.00 67 2,441.00 2,475.00 3,235.00 2,867.00 3,454.00 499.00 2,817.00 2,042.00 2,586.00 68 2,495.00 2,537.00 3,326.00 2,954.00 3,554.00 516.00 2,901.00 2,104.00 2,662.00 69 2,544.00 2,597.00 3,416.00 3,036.00 3,654.00 532.00 2,989.00 2,165.00 2,739.00 70 2,592.00 2,655.00 3,512.00 3,128.00 3,755.00 550.00 3,080.00 2,231.00 2,817.00 71 2,640.00 2,716.00 3,609.00 3,216.00 3,859.00 570.00 3,171.00 2,296.00 2,897.00 72 2,682.00 2,774.00 3,707.00 3,312.00 3,963.00 586.00 3,259.00 2,358.00 2,978.00 73 2,721.00 2,834.00 3,805.00 3,403.00 4,067.00 604.00 3,353.00 2,426.00 3,059.00 74 2,757.00 2,888.00 3,906.00 3,496.00 4,172.00 623.00 3,445.00 2,489.00 3,137.00 75 2,789.00 2,939.00 4,002.00 3,587.00 4,274.00 640.00 3,537.00 2,556.00 3,215.00 76 2,815.00 2,989.00 4,100.00 3,680.00 4,375.00 659.00 3,626.00 2,619.00 3,293.00 77 2,841.00 3,034.00 4,195.00 3,771.00 4,480.00 679.00 3,715.00 2,684.00 3,372.00 78 2,863.00 3,076.00 4,289.00 3,861.00 4,578.00 695.00 3,804.00 2,748.00 3,444.00 79 2,882.00 3,112.00 4,381.00 3,946.00 4,675.00 713.00 3,887.00 2,806.00 3,515.00 80 2,895.00 3,145.00 4,466.00 4,033.00 4,767.00 729.00 3,968.00 2,864.00 3,583.00 81 2,911.00 3,177.00 4,546.00 4,106.00 4,854.00 746.00 4,043.00 2,919.00 3,645.00 82 2,917.00 3,204.00 4,619.00 4,180.00 4,930.00 760.00 4,111.00 2,974.00 3,702.00 83 2,932.00 3,231.00 4,683.00 4,242.00 4,998.00 772.00 4,170.00 3,023.00 3,751.00 84 2,937.00 3,256.00 4,736.00 4,294.00 5,060.00 784.00 4,223.00 3,069.00 3,793.00 85 2,948.00 3,279.00 4,785.00 4,343.00 5,111.00 793.00 4,268.00 3,110.00 3,827.00 86 2,952.00 3,303.00 4,827.00 4,384.00 5,156.00 801.00 4,310.00 3,147.00 3,858.00 87 2,958.00 3,324.00 4,863.00 4,419.00 5,193.00 807.00 4,344.00 3,186.00 3,885.00 88 2,963.00 3,346.00 4,894.00 4,450.00 5,225.00 814.00 4,376.00 3,219.00 3,909.00 89 2,969.00 3,364.00 4,920.00 4,477.00 5,254.00 817.00 4,401.00 3,249.00 3,927.00 90 2,970.00 3,383.00 4,947.00 4,502.00 5,282.00 822.00 4,430.00 3,277.00 3,944.00 91 2,977.00 3,401.00 4,970.00 4,524.00 5,305.00 826.00 4,452.00 3,306.00 3,961.00 92 2,978.00 3,417.00 4,992.00 4,547.00 5,330.00 829.00 4,474.00 3,330.00 3,974.00 93 2,979.00 3,434.00 5,014.00 4,571.00 5,354.00 834.00 4,495.00 3,353.00 3,989.00 94 2,980.00 3,449.00 5,039.00 4,591.00 5,380.00 842.00 4,518.00 3,374.00 4,002.00 95 2,980.00 3,465.00 5,064.00 4,612.00 5,405.00 846.00 4,540.00 3,395.00 4,017.00 96 2,982.00 3,478.00 5,088.00 4,635.00 5,433.00 854.00 4,561.00 3,413.00 4,032.00 97 2,982.00 3,495.00 5,113.00 4,660.00 5,460.00 858.00 4,584.00 3,432.00 4,045.00 98 2,982.00 3,508.00 5,139.00 4,679.00 5,487.00 864.00 4,604.00 3,449.00 4,058.00 99 2,982.00 3,523.00 5,166.00 4,704.00 5,513.00 868.00 4,626.00 3,468.00 4,072.00


34726CA N7-19 Rev. 3-2020

ZIP 960-961 – Non-Smoker – Attained Age Chart shows $ amount for annual premium.


<64 2,498.50 2,680.90 3,738.25 3,364.90 3,990.95 621.30 3,308.85 2,477.60 2,981.10 64 1,677.70 1,604.55 1,986.45 1,684.35 2,122.30 284.05 1,657.75 1,232.15 1,542.80 65 1,677.70 1,604.55 1,986.45 1,684.35 2,122.30 284.05 1,657.75 1,232.15 1,542.80 66 1,724.25 1,634.00 2,038.70 1,734.70 2,180.25 293.55 1,710.00 1,270.15 1,589.35 67 1,772.70 1,697.65 2,096.65 1,789.80 2,240.10 304.00 1,760.35 1,311.95 1,637.80 68 1,847.75 1,773.65 2,181.20 1,871.50 2,331.30 318.25 1,840.15 1,371.80 1,710.95 69 1,922.80 1,849.65 2,266.70 1,951.30 2,422.50 332.50 1,921.85 1,432.60 1,785.05 70 1,994.05 1,926.60 2,351.25 2,035.85 2,513.70 348.65 2,003.55 1,493.40 1,858.20 71 2,065.30 2,000.70 2,439.60 2,118.50 2,605.85 364.80 2,086.20 1,556.10 1,932.30 72 2,131.80 2,071.95 2,525.10 2,200.20 2,699.90 380.95 2,166.95 1,614.05 2,007.35 73 2,190.70 2,142.25 2,615.35 2,285.70 2,796.80 396.15 2,250.55 1,677.70 2,081.45 74 2,244.85 2,208.75 2,703.70 2,374.05 2,890.85 415.15 2,336.05 1,740.40 2,157.45 75 2,292.35 2,272.40 2,794.90 2,460.50 2,985.85 431.30 2,419.65 1,805.95 2,233.45 76 2,336.05 2,331.30 2,889.90 2,550.75 3,086.55 448.40 2,510.85 1,870.55 2,309.45 77 2,370.25 2,385.45 2,983.00 2,641.95 3,186.30 466.45 2,600.15 1,939.90 2,386.40 78 2,401.60 2,433.90 3,080.85 2,732.20 3,291.75 485.45 2,691.35 2,008.30 2,466.20 79 2,427.25 2,479.50 3,177.75 2,827.20 3,394.35 504.45 2,782.55 2,075.75 2,542.20 80 2,447.20 2,521.30 3,276.55 2,921.25 3,499.80 524.40 2,876.60 2,146.05 2,622.00 81 2,461.45 2,558.35 3,372.50 3,012.45 3,605.25 544.35 2,965.90 2,217.30 2,697.05 82 2,472.85 2,593.50 3,469.40 3,107.45 3,705.00 564.30 3,058.05 2,286.65 2,773.05 83 2,485.20 2,622.95 3,563.45 3,197.70 3,806.65 583.30 3,145.45 2,353.15 2,845.25 84 2,492.80 2,653.35 3,652.75 3,282.25 3,901.65 603.25 3,230.95 2,415.85 2,915.55 85 2,498.50 2,680.90 3,738.25 3,364.90 3,990.95 621.30 3,308.85 2,477.60 2,981.10 86 2,505.15 2,707.50 3,819.00 3,442.80 4,078.35 640.30 3,387.70 2,536.50 3,043.80 87 2,511.80 2,732.20 3,894.05 3,515.95 4,160.05 653.60 3,459.90 2,586.85 3,098.90 88 2,516.55 2,759.75 3,960.55 3,581.50 4,229.40 665.00 3,524.50 2,637.20 3,152.10 89 2,521.30 2,784.45 4,024.20 3,639.45 4,295.90 676.40 3,578.65 2,679.95 3,197.70 90 2,528.90 2,811.05 4,079.30 3,693.60 4,355.75 684.95 3,632.80 2,720.80 3,239.50 91 2,533.65 2,832.90 4,129.65 3,743.00 4,409.90 694.45 3,682.20 2,757.85 3,276.55 92 2,538.40 2,860.45 4,176.20 3,786.70 4,462.15 702.05 3,725.90 2,792.05 3,308.85 93 2,542.20 2,886.10 4,220.85 3,829.45 4,507.75 709.65 3,767.70 2,821.50 3,344.00 94 2,546.00 2,907.95 4,261.70 3,869.35 4,549.55 715.35 3,806.65 2,850.95 3,372.50 95 2,550.75 2,934.55 4,301.60 3,907.35 4,591.35 722.95 3,842.75 2,878.50 3,400.05 96 2,556.45 2,956.40 4,338.65 3,941.55 4,630.30 728.65 3,876.95 2,905.10 3,424.75 97 2,560.25 2,982.05 4,375.70 3,976.70 4,669.25 734.35 3,912.10 2,931.70 3,450.40 98 2,564.05 3,005.80 4,408.95 4,011.85 4,709.15 740.05 3,944.40 2,956.40 3,477.00 99 2,575.45 3,042.85 4,461.20 4,062.20 4,761.40 749.55 3,994.75 2,995.35 3,516.90


34726CA N7-19 Rev. 3-2020

ZIP 960-961 – Non-Smoker – Issue Age Chart shows $ amount for annual premium.


<64 2,546.00 2,831.95 4,132.50 3,750.60 4,413.70 684.95 3,686.00 2,685.65 3,305.05 64 2,006.40 2,032.05 2,641.95 2,334.15 2,819.60 404.70 2,287.60 1,665.35 2,108.05 65 2,006.40 2,032.05 2,641.95 2,334.15 2,819.60 404.70 2,287.60 1,665.35 2,108.05 66 2,055.80 2,085.25 2,717.00 2,404.45 2,901.30 417.05 2,361.70 1,715.70 2,169.80 67 2,108.05 2,137.50 2,793.95 2,475.70 2,983.00 431.30 2,432.95 1,763.20 2,233.45 68 2,154.60 2,190.70 2,872.80 2,550.75 3,069.45 445.55 2,505.15 1,817.35 2,299.00 69 2,197.35 2,242.95 2,949.75 2,622.00 3,155.90 459.80 2,581.15 1,869.60 2,365.50 70 2,238.20 2,293.30 3,033.35 2,701.80 3,243.30 475.00 2,660.00 1,926.60 2,432.95 71 2,280.00 2,345.55 3,116.95 2,777.80 3,332.60 492.10 2,738.85 1,982.65 2,502.30 72 2,316.10 2,395.90 3,201.50 2,860.45 3,422.85 506.35 2,814.85 2,036.80 2,571.65 73 2,350.30 2,447.20 3,286.05 2,939.30 3,512.15 521.55 2,895.60 2,094.75 2,641.95 74 2,380.70 2,493.75 3,373.45 3,019.10 3,603.35 537.70 2,975.40 2,149.85 2,709.40 75 2,408.25 2,538.40 3,456.10 3,097.95 3,690.75 552.90 3,054.25 2,207.80 2,776.85 76 2,431.05 2,581.15 3,540.65 3,177.75 3,778.15 569.05 3,131.20 2,261.95 2,844.30 77 2,453.85 2,620.10 3,623.30 3,256.60 3,869.35 586.15 3,208.15 2,318.00 2,911.75 78 2,472.85 2,656.20 3,704.05 3,334.50 3,953.90 600.40 3,285.10 2,373.10 2,974.45 79 2,489.00 2,687.55 3,783.85 3,407.65 4,037.50 615.60 3,357.30 2,423.45 3,035.25 80 2,500.40 2,716.05 3,857.00 3,482.70 4,117.30 629.85 3,426.65 2,473.80 3,094.15 81 2,513.70 2,743.60 3,926.35 3,546.35 4,192.35 644.10 3,491.25 2,521.30 3,148.30 82 2,519.40 2,767.35 3,989.05 3,610.00 4,257.90 656.45 3,550.15 2,568.80 3,196.75 83 2,531.75 2,790.15 4,044.15 3,663.20 4,316.80 666.90 3,601.45 2,610.60 3,239.50 84 2,536.50 2,812.00 4,089.75 3,708.80 4,370.00 677.35 3,647.05 2,650.50 3,275.60 85 2,546.00 2,831.95 4,132.50 3,750.60 4,413.70 684.95 3,686.00 2,685.65 3,305.05 86 2,549.80 2,852.85 4,168.60 3,785.75 4,452.65 691.60 3,722.10 2,717.95 3,331.65 87 2,554.55 2,870.90 4,199.95 3,816.15 4,484.95 697.30 3,751.55 2,751.20 3,355.40 88 2,559.30 2,889.90 4,226.55 3,842.75 4,512.50 703.00 3,779.10 2,779.70 3,376.30 89 2,564.05 2,905.10 4,249.35 3,866.50 4,537.20 705.85 3,800.95 2,806.30 3,391.50 90 2,565.00 2,921.25 4,272.15 3,888.35 4,561.90 709.65 3,825.65 2,830.05 3,405.75 91 2,570.70 2,937.40 4,292.10 3,907.35 4,581.85 713.45 3,844.65 2,854.75 3,420.95 92 2,571.65 2,950.70 4,311.10 3,927.30 4,602.75 716.30 3,863.65 2,875.65 3,432.35 93 2,572.60 2,965.90 4,330.10 3,947.25 4,623.65 720.10 3,881.70 2,895.60 3,444.70 94 2,573.55 2,978.25 4,351.95 3,965.30 4,646.45 726.75 3,901.65 2,913.65 3,456.10 95 2,573.55 2,992.50 4,373.80 3,983.35 4,668.30 730.55 3,920.65 2,931.70 3,469.40 96 2,575.45 3,003.90 4,393.75 4,003.30 4,692.05 737.20 3,938.70 2,947.85 3,481.75 97 2,575.45 3,018.15 4,415.60 4,024.20 4,715.80 741.00 3,958.65 2,964.00 3,493.15 98 2,575.45 3,029.55 4,438.40 4,041.30 4,738.60 745.75 3,975.75 2,978.25 3,504.55 99 2,575.45 3,042.85 4,461.20 4,062.20 4,761.40 749.55 3,994.75 2,995.35 3,516.90


34726CA N7-19 Rev. 3-2020

ZIP 960-961 – Smoker – Attained Age Chart shows $ amount for annual premium.


<64 2,748.35 2,948.80 4,112.55 3,701.20 4,389.95 683.05 3,639.45 2,725.55 3,279.40 64 1,845.85 1,765.10 2,185.00 1,852.50 2,334.15 312.55 1,824.00 1,355.65 1,696.70 65 1,845.85 1,765.10 2,185.00 1,852.50 2,334.15 312.55 1,824.00 1,355.65 1,696.70 66 1,897.15 1,797.40 2,242.95 1,908.55 2,398.75 323.00 1,881.00 1,397.45 1,748.00 67 1,950.35 1,867.70 2,306.60 1,968.40 2,464.30 334.40 1,936.10 1,443.05 1,801.20 68 2,033.00 1,951.30 2,399.70 2,058.65 2,564.05 350.55 2,024.45 1,508.60 1,881.95 69 2,114.70 2,034.90 2,493.75 2,146.05 2,664.75 365.75 2,113.75 1,576.05 1,963.65 70 2,193.55 2,119.45 2,586.85 2,239.15 2,765.45 383.80 2,204.00 1,642.55 2,044.40 71 2,271.45 2,201.15 2,683.75 2,330.35 2,866.15 400.90 2,295.20 1,711.90 2,125.15 72 2,344.60 2,279.05 2,777.80 2,420.60 2,969.70 418.95 2,383.55 1,775.55 2,207.80 73 2,410.15 2,356.95 2,876.60 2,514.65 3,076.10 436.05 2,475.70 1,845.85 2,289.50 74 2,469.05 2,430.10 2,974.45 2,611.55 3,179.65 456.95 2,569.75 1,914.25 2,373.10 75 2,521.30 2,499.45 3,074.20 2,706.55 3,284.15 474.05 2,661.90 1,986.45 2,456.70 76 2,569.75 2,564.05 3,178.70 2,806.30 3,395.30 493.05 2,761.65 2,057.70 2,540.30 77 2,607.75 2,623.90 3,281.30 2,906.05 3,504.55 513.00 2,860.45 2,133.70 2,624.85 78 2,641.95 2,677.10 3,388.65 3,005.80 3,621.40 533.90 2,960.20 2,208.75 2,713.20 79 2,670.45 2,727.45 3,496.00 3,110.30 3,733.50 554.80 3,060.90 2,283.80 2,796.80 80 2,692.30 2,773.05 3,604.30 3,213.85 3,849.40 576.65 3,164.45 2,360.75 2,884.20 81 2,707.50 2,813.90 3,709.75 3,313.60 3,966.25 598.50 3,262.30 2,438.65 2,966.85 82 2,719.85 2,852.85 3,816.15 3,418.10 4,075.50 620.35 3,363.95 2,515.60 3,050.45 83 2,734.10 2,885.15 3,919.70 3,517.85 4,187.60 641.25 3,459.90 2,588.75 3,130.25 84 2,741.70 2,918.40 4,018.50 3,610.95 4,292.10 664.05 3,553.95 2,657.15 3,207.20 85 2,748.35 2,948.80 4,112.55 3,701.20 4,389.95 683.05 3,639.45 2,725.55 3,279.40 86 2,755.95 2,978.25 4,200.90 3,786.70 4,485.90 703.95 3,726.85 2,790.15 3,347.80 87 2,762.60 3,005.80 4,283.55 3,867.45 4,576.15 719.15 3,805.70 2,845.25 3,408.60 88 2,768.30 3,036.20 4,356.70 3,939.65 4,652.15 731.50 3,876.95 2,901.30 3,467.50 89 2,773.05 3,062.80 4,427.00 4,003.30 4,725.30 743.85 3,936.80 2,947.85 3,517.85 90 2,781.60 3,092.25 4,486.85 4,063.15 4,791.80 753.35 3,995.70 2,992.50 3,563.45 91 2,787.30 3,116.00 4,542.90 4,117.30 4,850.70 763.80 4,050.80 3,033.35 3,604.30 92 2,792.05 3,146.40 4,594.20 4,165.75 4,908.65 772.35 4,098.30 3,071.35 3,639.45 93 2,796.80 3,174.90 4,642.65 4,212.30 4,959.00 780.90 4,144.85 3,103.65 3,678.40 94 2,800.60 3,198.65 4,688.25 4,256.00 5,004.60 786.60 4,187.60 3,135.95 3,709.75 95 2,806.30 3,228.10 4,731.95 4,297.80 5,050.20 795.15 4,227.50 3,166.35 3,740.15 96 2,812.00 3,251.85 4,772.80 4,335.80 5,092.95 801.80 4,264.55 3,195.80 3,767.70 97 2,816.75 3,280.35 4,813.65 4,374.75 5,136.65 807.50 4,303.50 3,225.25 3,795.25 98 2,820.55 3,306.00 4,849.75 4,412.75 5,180.35 814.15 4,338.65 3,251.85 3,824.70 99 2,832.90 3,346.85 4,907.70 4,468.80 5,237.35 824.60 4,394.70 3,294.60 3,868.40


34726CA N7-19 Rev. 3-2020

ZIP 960-961 – Smoker – Issue Age Chart shows $ amount for annual premium.


<64 2,800.60 3,115.05 4,545.75 4,125.85 4,855.45 753.35 4,054.60 2,954.50 3,635.65 64 2,206.85 2,235.35 2,906.05 2,567.85 3,101.75 445.55 2,516.55 1,831.60 2,318.95 65 2,206.85 2,235.35 2,906.05 2,567.85 3,101.75 445.55 2,516.55 1,831.60 2,318.95 66 2,261.00 2,294.25 2,988.70 2,644.80 3,191.05 458.85 2,598.25 1,887.65 2,386.40 67 2,318.95 2,351.25 3,073.25 2,723.65 3,281.30 474.05 2,676.15 1,939.90 2,456.70 68 2,370.25 2,410.15 3,159.70 2,806.30 3,376.30 490.20 2,755.95 1,998.80 2,528.90 69 2,416.80 2,467.15 3,245.20 2,884.20 3,471.30 505.40 2,839.55 2,056.75 2,602.05 70 2,462.40 2,522.25 3,336.40 2,971.60 3,567.25 522.50 2,926.00 2,119.45 2,676.15 71 2,508.00 2,580.20 3,428.55 3,055.20 3,666.05 541.50 3,012.45 2,181.20 2,752.15 72 2,547.90 2,635.30 3,521.65 3,146.40 3,764.85 556.70 3,096.05 2,240.10 2,829.10 73 2,584.95 2,692.30 3,614.75 3,232.85 3,863.65 573.80 3,185.35 2,304.70 2,906.05 74 2,619.15 2,743.60 3,710.70 3,321.20 3,963.40 591.85 3,272.75 2,364.55 2,980.15 75 2,649.55 2,792.05 3,801.90 3,407.65 4,060.30 608.00 3,360.15 2,428.20 3,054.25 76 2,674.25 2,839.55 3,895.00 3,496.00 4,156.25 626.05 3,444.70 2,488.05 3,128.35 77 2,698.95 2,882.30 3,985.25 3,582.45 4,256.00 645.05 3,529.25 2,549.80 3,203.40 78 2,719.85 2,922.20 4,074.55 3,667.95 4,349.10 660.25 3,613.80 2,610.60 3,271.80 79 2,737.90 2,956.40 4,161.95 3,748.70 4,441.25 677.35 3,692.65 2,665.70 3,339.25 80 2,750.25 2,987.75 4,242.70 3,831.35 4,528.65 692.55 3,769.60 2,720.80 3,403.85 81 2,765.45 3,018.15 4,318.70 3,900.70 4,611.30 708.70 3,840.85 2,773.05 3,462.75 82 2,771.15 3,043.80 4,388.05 3,971.00 4,683.50 722.00 3,905.45 2,825.30 3,516.90 83 2,785.40 3,069.45 4,448.85 4,029.90 4,748.10 733.40 3,961.50 2,871.85 3,563.45 84 2,790.15 3,093.20 4,499.20 4,079.30 4,807.00 744.80 4,011.85 2,915.55 3,603.35 85 2,800.60 3,115.05 4,545.75 4,125.85 4,855.45 753.35 4,054.60 2,954.50 3,635.65 86 2,804.40 3,137.85 4,585.65 4,164.80 4,898.20 760.95 4,094.50 2,989.65 3,665.10 87 2,810.10 3,157.80 4,619.85 4,198.05 4,933.35 766.65 4,126.80 3,026.70 3,690.75 88 2,814.85 3,178.70 4,649.30 4,227.50 4,963.75 773.30 4,157.20 3,058.05 3,713.55 89 2,820.55 3,195.80 4,674.00 4,253.15 4,991.30 776.15 4,180.95 3,086.55 3,730.65 90 2,821.50 3,213.85 4,699.65 4,276.90 5,017.90 780.90 4,208.50 3,113.15 3,746.80 91 2,828.15 3,230.95 4,721.50 4,297.80 5,039.75 784.70 4,229.40 3,140.70 3,762.95 92 2,829.10 3,246.15 4,742.40 4,319.65 5,063.50 787.55 4,250.30 3,163.50 3,775.30 93 2,830.05 3,262.30 4,763.30 4,342.45 5,086.30 792.30 4,270.25 3,185.35 3,789.55 94 2,831.00 3,276.55 4,787.05 4,361.45 5,111.00 799.90 4,292.10 3,205.30 3,801.90 95 2,831.00 3,291.75 4,810.80 4,381.40 5,134.75 803.70 4,313.00 3,225.25 3,816.15 96 2,832.90 3,304.10 4,833.60 4,403.25 5,161.35 811.30 4,332.95 3,242.35 3,830.40 97 2,832.90 3,320.25 4,857.35 4,427.00 5,187.00 815.10 4,354.80 3,260.40 3,842.75 98 2,832.90 3,332.60 4,882.05 4,445.05 5,212.65 820.80 4,373.80 3,276.55 3,855.10 99 2,832.90 3,346.85 4,907.70 4,468.80 5,237.35 824.60 4,394.70 3,294.60 3,868.40


34726CA N7-19 Rev. 3-2020

PREMIUM INFORMATION

We, Thrivent Financial for Lutherans, can only raise your premium if we raise the premium for all policies like yours in California. If your charge is based on attained age, your renewal charge will increase due to age on or after the contract anniversary.

RIGHT TO CHANGE YOUR PREMIUM STRUCTURE You will have the right to change your premium structure on any renewal date. You may change from Attained Age premiums to Issue Age

premiums. If you change, you will be charged the premium that applies to your age at the time of the change.

NOTICE

Use this outline to compare benefits and premiums among policies.

READ YOUR POLICY VERY CAREFULLY

This is only an outline describing your policy’s most important features. The policy is your insurance contract. You must read the policy itself to understand all the rights and duties of both you and your insurance company.

THIRTY-DAY RIGHT TO RETURN POLICY

If you find that you are not satisfied with your policy, you may return it to Thrivent Financial for Lutherans, 4321 N. Ballard Road, Appleton,

WI, 54919-0001. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it has never been issued and return all of your payments. POLICY REPLACEMENT

If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.

DISCLOSURES

This contract may not fully cover all of your medical costs.

Neither this company nor its agents are connected with Medicare.

This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult ‘The Medicare Handbook’ for more details.

For additional information concerning policy benefits, contact the Health Insurance and Counseling and Advocacy Program (HICAP) or your agent. Call the HICAP toll-free telephone number, 1-800-434-0222, for a referral to your local HICAP office. HICAP is a service provided free of charge by the State of California.

COMPLETE ANSWERS ARE IMPORTANT

When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.

Read the application carefully before you sign it. Be certain that all information has been properly recorded.

34726CA N7-19 Rev. 3-2020

PLAN A MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing,

and miscellaneous services and supplies

First 60 days All but $[1408] $0 $[1408] (Part A deductible)

61st through 90th day All but $[352] a day $[352] a day $0 91st day and after:

- While using 60 lifetime reserve days

- Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days

All but $[704] a day

$0 $0

$[704] a day

100% of Medicare eligible expenses $0

$0

$0** All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for

at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days All approved amounts $0 $0

21st through 100th day All but $[176] a day $0 Up to $[176] a day 101st day and after $0 $0 All costs

BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0

HOSPICE CARE You must meet Medicare’s requirements,

including a doctor’s certification of terminal illness

All but very limited copayment/coinsurance for

outpatient drugs and inpatient respite care

Medicare copayment/coinsurance $0

(continued)

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s Basic Benefits. During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

34726CA N7-19 Rev. 3-2020

PLAN A MEDICARE (PART B) – MEDICAL EXPENSES – PER CALENDAR YEAR

*Once you have been billed $[198] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.


MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND

OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy,

diagnostic tests, durable medical equipment

First $[198] of Medicare Approved Amounts* $0 $0 $[198] (Part B deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0

PART B EXCESS CHARGES (Above Medicare Approved Amounts)

$0

$0

All costs

BLOOD First 3 pints $0 All costs $0

Next $[198] of Medicare Approved Amounts* $0 $0 $[198] (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0

CLINICAL LABORATORY SERVICES— TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B


HOME HEALTH CARE— MEDICARE APPROVED SERVICES

Medically necessary skilled care services and medical supplies

100% $0 $0

Durable medical equipment

First $[198] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts

$0 80%

$0 20%

$[198] (Part B deductible) $0

Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

34726CA N7-19 Rev. 3-2020

PLAN B MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD





First 60 days All but $[1408] $[1408] (Part A deductible) $0





$0 $0

$[704] a day


$0

$0** All costs




21st through 100th day All but $[176] a day $0 Up to $[176] a day 101st day and after $0 $0 All costs







(continued)


34726CA N7-19 Rev. 3-2020

PLAN B MEDICARE (PART B) – MEDICAL EXPENSES – PER CALENDAR YEAR








$0

$0

All costs




100%

$0

$0

PARTS A & B




100% $0 $0



$0 80%

$0 20%



34726CA N7-19 Rev. 3-2020

PLAN C MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD










$0 $0

$[704] a day


$0

$0** All costs




21st through 100th day All but $[176] a day Up to $[176] a day $0 101st day and after $0 $0 All costs







(continued)


34726CA N7-19 Rev. 3-2020

PLAN C MEDICARE (PART B) – MEDICAL EXPENSES – PER CALENDAR YEAR






First $[198] of Medicare Approved Amounts* $0 $[198] (Part B deductible) $0 Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0


$0

$0

All costs


Next $[198] of Medicare Approved Amounts* $0 $[198] (Part B deductible) $0 Remainder of Medicare Approved Amounts 80% 20% $0


100%

$0

$0

PARTS A & B



Medically necessary skilled care services and

medical supplies

100% $0 $0

Durable medical equipment First $[198] of Medicare Approved Amounts*

Remainder of Medicare Approved Amounts

$0

80%

$[198] (Part B deductible)

20%

$0

$0

(continued)

34726CA N7-19 Rev. 3-2020

PLAN C OTHER BENEFITS – NOT COVERED BY MEDICARE


FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip

outside the USA

First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of

$50,000 20% and amounts over the $50,000 lifetime maximum


34726CA N7-19 Rev. 3-2020

PLAN D MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD










$0 $0

$[704] a day


$0

$0** All costs











(continued)


34726CA N7-19 Rev. 3-2020

PLAN D MEDICARE (PART B) – MEDICAL EXPENSES – PER CALENDAR YEAR








$0

$0

All costs




100%

$0

$0

PARTS A & B




medical supplies

100% $0 $0



$0

80%

$0

20%


$0

(continued)

34726CA N7-19 Rev. 3-2020

PLAN D OTHER BENEFITS – NOT COVERED BY MEDICARE



outside the USA




34726CA N7-19 Rev. 3-2020

PLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD










$0 $0

$[704] a day


$0

$0** All costs











(continued)


34726CA N7-19 Rev. 3-2020

PLAN F MEDICARE (PART B) – MEDICAL EXPENSES – PER CALENDAR YEAR








$0

100%

$0


Next $[198] of Medicare Approved Amounts* $0 $[198] (Part B deductible) $0 Remainder of Medicare Approved Amounts 80% 20% $0


100%

$0

$0

PARTS A & B




medical supplies

100% $0 $0



$0

80%


20%

$0

$0

(continued)

34726CA N7-19 Rev. 3-2020

PLAN F OTHER BENEFITS – NOT COVERED BY MEDICARE



outside the USA




34726CA N7-19 Rev. 3-2020

HIGH DEDUCTIBLE PLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD


^This high deductible plan pays the same benefits as Plan F after you have paid a calendar year $[2340] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[2340]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.

SERVICES MEDICARE PAYS AFTER YOU PAY$[2340] DEDUCTIBLE , PLAN PAYS

IN ADDITION TO $[2340] DEDUCTIBLE ,

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies


61st through 90th day All but $[352] a day $[352] a day $0

91st day and after: - While using 60 lifetime reserve days - Once lifetime reserve days are used:

- Additional 365 days

- Beyond the additional 365 days

All but $[704] a day $0

$0

$[704] a day 100% of Medicare eligible expenses

$0

$0 $0**

All costs SKILLED NURSING FACILITY CARE*

You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days

after leaving the hospital

First 20 days All approved amounts $0 $0 21st through 100th day All but $[176] a day Up to $[176] a day $0 101st day and after $0 $0 All costs

(continued)


34726CA N7-19 Rev. 3-2020

HIGH DEDUCTIBLE PLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

^This high deductible plan pays the same benefits as Plan F after you have paid a calendar year $[2340] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[2340]. Out-of-pocket expenses for this deductible are expenses

that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.



YOU PAY

BLOOD First 3 pints $0 3 pints $0

Additional amounts 100% $0 $0 HOSPICE CARE

You must meet Medicare’s requirements, including a doctor’s certification of terminal illness

All but very limited

copayment/coinsurance for outpatient drugs and inpatient respite care


(continued)

34726CA N7-19 Rev. 3-2020

HIGH DEDUCTIBLE PLAN F MEDICARE (PART B) – MEDICAL EXPENSES – PER CALENDAR YEAR

*Once you have been billed $[198] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will

have been met for the calendar year.

^This high deductible plan pays the same benefits as Plan F after you have paid a calendar year $[2340] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[2340]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s

separate foreign travel emergency deductible. SERVICES MEDICARE PAYS AFTER YOU PAY$[2340]

DEDUCTIBLE , PLAN PAYS

IN ADDITION TO $[2340]

DEDUCTIBLE , YOU PAY

MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT,

such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment



$0

100%

$0

BLOOD First 3 pints $0 All costs $0 Next $[198] of Medicare Approved Amounts* $0 $[198] (Part B deductible) $0

Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES—

TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

(continued)

34726CA N7-19 Rev. 3-2020

HIGH DEDUCTIBLE PLAN F PARTS A & B

*Once you have been billed $[198] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will

have been met for the calendar year.

^This high deductible plan pays the same benefits as Plan F after you have paid a calendar year $[2340] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $[2340]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s

separate foreign travel emergency deductible. SERVICES MEDICARE PAYS AFTER YOU PAY$[2340]

DEDUCTIBLE , PLAN PAYS

IN ADDITION TO $[2340]

DEDUCTIBLE , YOU PAY



100% $0 $0



$0 80%

$[198] (Part B deductible) 20%

$0 $0

OTHER BENEFITS – NOT COVERED BY MEDICARE



YOU PAY

FOREIGN TRAVEL NOT COVERED BY MEDICARE

Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year $0 $0 $250

Remainder of charges $0 80% to a lifetime maximum benefit of $50,000

20% and amounts over the $50,000 lifetime maximum


34726CA N7-19 Rev. 3-2020

PLAN G MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD










$0 $0

$[704] a day


$0

$0** All costs











(continued)


34726CA N7-19 Rev. 3-2020

PLAN G MEDICARE (PART B) – MEDICAL EXPENSES – PER CALENDAR YEAR








$0

100%

$0




100%

$0

$0

PARTS A & B




medical supplies

100% $0 $0



$0

80%

$0

20%


$0

(continued)

34726CA N7-19 Rev. 3-2020

PLAN G OTHER BENEFITS – NOT COVERED BY MEDICARE



outside the USA




34726CA N7-19 Rev. 3-2020

PLAN L MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[2940] each calendar year. The amounts that count toward your annual limit are noted with diamonds (⧫) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this

difference in the amount charged by your provider and the amount paid by Medicare for the item or service. *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.




First 60 days All but $[1408] $[1056] (75% of Part A deductible) $[352] (25% of Part A

deductible)⧫ 61st through 90th day All but $[352] a day $[352] a day $0





$0


$0

$0 $0**

All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a

Medicare-approved facility within 30 days after leaving the hospital

First 20 days All approved amounts $0 $0 21st through 100th day All but $[176] a day Up to $[132] a day $Up to $[44] a day (25% of

Part A coinsurance)⧫ 101st day and after $0 $0 All costs

(continued) **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s Basic Benefits. During this time the hospital is prohibited from

billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

34726CA N7-19 Rev. 3-2020

PLAN L MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD


BLOOD First 3 pints $0 75% 25%⧫

Additional amounts 100% $0 $0

HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

75% of copayment/coinsurance 25% of copayment/ coinsurance⧫

(continued)

34726CA N7-19 Rev. 3-2020

PLAN L MEDICARE (PART B) – MEDICAL EXPENSES – PER CALENDAR YEAR






First $[198] of Medicare Approved Amounts*

$0 $0 $[198] (Part B deductible)* ⧫

Preventive Benefits for Medicare Covered Services

Generally 80% or more of Medicare approved

amounts

Remainder of Medicare approved amounts

All costs above Medicare approved amounts

Remainder of Medicare Approved Amounts Generally 80% Generally 15% Generally 5% ⧫


$0

$0

All costs (and they do not

count toward annual out-of-pocket limit of $[2,780]

BLOOD First 3 pints $0 75% 25%⧫ Next $[198] of Medicare Approved Amounts* $0 $0 $[198] (Part B

deductible)* ⧫ Remainder of Medicare Approved Amounts Generally 80% Generally 15% Generally 5%⧫


100%

$0

$0

(continued) This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[2940] per year. However, this limit does NOT include

charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

34726CA N7-19 Rev. 3-2020

PLAN L MEDICARE (PART B) – MEDICAL EXPENSES – PER CALENDAR YEAR





100% $0 $0

Durable medical equipment First $[198] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts

$0 80%

$0 15%

$[198] (Part B deductible)* ⧫ 5%⧫


34726CA N7-19 Rev. 3-2020

PLAN M MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD





First 60 days All but $[1408] $[704] (50% of Part A deductible) $[704] (50% of Part A

deductible) 61st through 90th day All but $[352] a day $[352] a day $0





$0


$0

$0 $0**

All costs SKILLED NURSING FACILITY CARE*

You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days

after leaving the hospital

First 20 days All approved amounts $0 $0 21st through 100th day All but $[176] a day Up to $[176] a day $0 101st day and after $0 $0 All costs

BLOOD

First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0

HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care


(continued) **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount

Medicare would have paid for up to an additional 365 days as provided in the policy’s Basic Benefits. During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

34726CA N7-19 Rev. 3-2020

PLAN M MEDICARE (PART B) – MEDICAL EXPENSES – PER CALENDAR YEAR








$0

$0

All costs




100%

$0

$0

PARTS A & B




100% $0 $0



$0 80%

$0 20%


(continued)

34726CA N7-19 Rev. 3-2020

PLAN M OTHER BENEFITS – NOT COVERED BY MEDICARE


FOREIGN TRAVEL NOT COVERED BY MEDICARE

Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year $0 $0 $250

Remainder of charges $0 80% to a lifetime maximum benefit of $50,000

20% and amounts over the $50,000 lifetime maximum


Outline of Medicare Supplement Coverage

Documents

Transcript of Outline of Medicare Supplement Coverage