Section 125 Supplemental Benefits RFP. Additional Information as requested by several potential vendors. Current Plan Rates and History Data

(1)

Section 125 Supplemental Benefits – RFP

Additional Information as requested by several potential vendors

(2)

MetLife Benefit Providers Passive PPO

Monthly Rates 7/1/2019-6/30/2021

Employee Only $34.85

Employee & Spouse $74.31

Employee & Child(ren) $80.80

Employee & Family $120.78

Benefit Providers Monthly Rates 7/1/2004 - 6/30/2006 7/1/2006 - 6/30/2009 7/1/2011 - 6/30/2013 7/1/2012 - 6/30/2013 7/1/2013 - 6/30/2016 7/1/2016 - 6/30/2018 Employee Only $25.22 $26.48 $29.60 $29.60 $31.97 $34.85

Employee & Spouse $53.88 $56.57 $63.12 $63.12 $68.17 $74.31

Employee & Child(ren) $56.14 $58.95 $68.64 $68.64 $74.13 $80.80

Employee & Family $84.80 $89.04 $102.60 $102.60 $110.81 $120.78

Vance County Schools

Dental Coverage

Dental History

(3)

VANCE COUNTY SCHOOLS

Monthly Claim View - Dental

From: 01/01/2017 To : 11/30/2020

Report Parameters:

Customer Number: 0106116

Experience Number: All

Report Number: All

Subcode: All

Branch: All

Coverage Code: DENT

Group By: Subcode

***If this is the only page you received please return to Edit this Report Package and review your parameter selections from the 'Re-run

the Report Package Wizard' option.

(4)

VANCE COUNTY SCHOOLS

Monthly Claim View - Dental

From: 01/01/2017 To: 11/01/2020

Date

Claims (non-ortho)

Personal Paid

Claims (non-ortho)

Dependent Paid

Orthodontia Paid

Claims

Total Paid Claims

Total Claim

Counts

Customer - 106116 Experience - 148961 Report - 148961 Subcode - 0001

01/2017

$12,433.40

$7,934.00

$610.50

$20,977.90

119 02/2017

$11,713.80

$4,370.90

$328.50

$16,413.20

113 03/2017

$13,604.50

$4,620.60

$872.00

$19,097.10

108 04/2017

$15,500.00

$6,429.70

$328.50

$22,258.20

126 05/2017

$13,061.50

$6,078.60

$631.50

$19,771.60

132 06/2017

$14,744.00

$5,844.30

$574.50

$21,162.80

120 07/2017

$18,118.70

$8,378.84

$982.50

$27,480.04

149 08/2017

$18,872.30

$13,506.55

$141.00

$32,519.85

181 09/2017

$10,040.40

$4,127.80

$1,684.50

$15,852.70

96 10/2017

$10,309.50

$5,818.00

$581.50

$16,709.00

102 11/2017

$9,070.10

$2,361.00

$280.50

$11,711.60

91 12/2017

$11,251.60

$4,639.80

$574.00

$16,465.40

87 01/2018

$13,134.20

$7,500.90

$865.00

$21,500.10

130 02/2018

$12,051.70

$6,417.73

$468.00

$18,937.43

137 03/2018

$15,422.20

$9,295.00

$385.50

$25,102.70

158 04/2018

$13,163.30

$7,917.20

$187.50

$21,268.00

143 05/2018

$13,808.60

$5,010.80

$1,264.50

$20,083.90

118 06/2018

$6,341.30

$7,342.50

$375.00

$14,058.80

98 07/2018

$16,711.95

$9,673.90

$187.50

$26,573.35

152 08/2018

$21,651.40

$14,511.22

$1,260.00

$37,422.62

205 09/2018

$8,599.90

$4,580.80

$63.00

$13,243.70

77

12/11/2020 10:18:41 AM Page 2 of 4

(5)

VANCE COUNTY SCHOOLS

Monthly Claim View - Dental

From: 01/01/2017 To: 11/01/2020

Date

Claims (non-ortho)

Personal Paid

Claims (non-ortho)

Dependent Paid

Orthodontia Paid

Claims

Total Paid Claims

Total Claim

Counts

10/2018

$11,418.10

$8,298.90

$453.00

$20,170.00

121 11/2018

$11,290.10

$6,228.60

$1,032.00

$18,550.70

127 12/2018

$7,720.20

$3,676.80

$427.50

$11,824.50

83 01/2019

$14,734.90

$4,257.30

$62.50

$19,054.70

115 02/2019

$11,072.50

$8,807.35

$843.00

$20,722.85

133 03/2019

$12,460.70

$5,561.10

$800.00

$18,821.80

118 04/2019

$13,324.12

$5,466.10

$0.00

$18,790.22

138 05/2019

$16,912.80

$7,814.00

$1,218.00

$25,944.80

152 06/2019

$13,397.70

$5,771.40

$160.50

$19,329.60

105 07/2019

$15,118.10

$9,512.40

$826.50

$25,457.00

163 08/2019

$14,632.90

$8,817.80

$937.50

$24,388.20

168 09/2019

$11,040.10

$2,973.80

$799.50

$14,813.40

99 10/2019

$11,707.40

$6,146.80

$375.00

$18,229.20

127 11/2019

$12,590.10

$8,334.10

$860.00

$21,784.20

124 12/2019

$14,414.70

$4,999.80

$375.00

$19,789.50

111 01/2020

$14,771.98

$8,826.23

$650.50

$24,248.71

120 02/2020

$7,463.40

$4,480.60

$482.00

$12,426.00

82 03/2020

$5,936.20

$3,733.50

$696.00

$10,365.70

71 04/2020

$2,177.66

$1,422.80

$562.50

$4,162.96

28 05/2020

$1,799.80

$3,019.10

$1,141.60

$5,960.50

32 06/2020

$12,326.30

$7,845.30

$208.50

$20,380.10

116 07/2020

$12,962.80

$8,156.81

$562.50

$21,682.11

143

12/11/2020 10:18:41 AM Page 3 of 4

(6)

VANCE COUNTY SCHOOLS

Monthly Claim View - Dental

From: 01/01/2017 To: 11/01/2020

Date

Claims (non-ortho)

Personal Paid

Claims (non-ortho)

Dependent Paid

Orthodontia Paid

Claims

Total Paid Claims

Total Claim

Counts

08/2020

$11,945.40

$5,501.20

$602.00

$18,048.60

107 09/2020

$7,274.80

$3,320.70

$562.50

$11,158.00

77 10/2020

$5,919.70

$7,504.00

$350.00

$13,773.70

82 11/2020

$6,888.00

$6,418.40

$1,079.50

$14,385.90

83 Subcode Total:

$560,904.81

$303,255.03

$28,713.10

$892,872.94

5467

Customer - 106116 Experience - 148961 Report - 148961 Subcode - 0002

01/2017

$380.00

$0.00

$380.00

1 Subcode Total:

$380.00

$0.00

$380.00

1 Customer Total:

$561,284.81

$303,255.03

$28,713.10

$893,252.94

5468

(7)

Vance County

Schools

VISION Plan and History

Benefit Provision Comprehensive

12 Month Rates July 1, 2020 - June 30, 2024

Employee Only $10.77

Employee + 1 $18.41

Employee + Family $31.74

Percent Rate Change

* Contact lenses are in lieu of eyeglass lenses and frames ^$25.00 copay for contact lenses

PLAN HISTORY

Benefit Provision

12 Month Rates

Employee Only Employee plus 1 Employee & Family

12 Month Rates

N/A Comprehensive Vision Plan Materials Only Plan Comprehensive Vision Plan Materials Only Plan

Comprehensive Vision Plan

This information is for comparison purposes only, please see proposal for specific coverage/limitations. Pricing/Benefits are subject to change. Upon receiving policy, please see the insurance carrier certificate/policy

for a complete list of policy provisions.

N/A N/A

N/A

Materials Only Plan Comprehensive Vision Plan Materials Only Plan Comprehensive Vision Plan

7/1/15-6/30/16

7/1/11-6/30/14 7/1/11-6/30/14 7/1/14-6/30/15 7/1/14-6/30/15 7/1/15-6/30/16

Materials Only Plan

7/1/04-6/30/05 7/1/04-6/30/05 7/1/05-6/30/11 7/1/05-6/30/11 $5.23 $10.88 $7.19 $11.42 $7.55 $9.13 $5.78 $9.30 $5.90 $7.91 $23.32 $13.60 $32.07 $18.70 $33.67 $19.64 $13.53 $7.58 $18.60 $10.42 $19.53

Comprehensive Vision Plan Materials Only Plan

$10.94

$22.91 $14.50 $23.36 $14.80

7/1/16-6/30/20 7/1/16-6/30/20

Superior Vision Superior Vision

OptiCare Vision OptiCare Vision OptiCare Vision

Envolve Vision

$19.53 $10.94

$33.67 $19.64

(8)

Colonial Life Benefit Provisions Basic Term Life & AD&D

12 Month Rates 7/1/20-6/30/21

EE Life $0.145/$1,000

EE AD&D $0.02/$1,000

The Hartford Colonial Life Benefit Provisions Basic Term Life & AD&D Basic Term Life & AD&D

12 Month Rates 7/1/11-6/30/18 7/1/18-6/30/20

EE Life $0.15/$1,000 $0.145/$1,000

EE AD&D $0.02/$1,000 $0.02/$1,000

Vance County Schools

Basic Group Term Life Coverage

(9)

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(12)

Applicable to AK, AL, AR, AZ, DE, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, NC, ND, NE, NH, NM, NV, OH, OK, OR, PA, SC, SD, TN, TX, UT, VA, WA, WI, WV Cancer Assist – PS01840 Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. This information is only intended for proposal use with employers.

Colonial Life & Accident Insurance Company 1200 Colonial Life Boulevard, Columbia, South Carolina 29210 08/16

Individual Cancer Rates

LEVEL 1

– Monthly Premiums - Composite Rates

Employee

/Spouse

One-Parent

Family

Two-Parent

Family

Level 1 WITHOUT Cancer Wellness/Health Screening

Premium

$11.45 $18.25 $11.60 $18.40

Level 1 with $25 Cancer Wellness/Health Screening

Premium

$12.90 $20.50 $13.05 $20.65

Level 1 with $50 Cancer Wellness/Health Screening

Premium

$14.35 $22.75 $14.50 $22.90

Level 1 with $75 Cancer Wellness/Health Screening

Premium

$16.20 $25.65 $16.35 $25.80

Level 1 with $100 Cancer Wellness/Health Screening

Premium

$18.10 $28.60 $18.25 $28.75

LEVEL 2

– Monthly Premiums - Composite Rates

Employee

/Spouse

One-Parent

Family

Two-Parent

Family

Level 2 WITHOUT Cancer Wellness/Health Screening

Premium

$15.00 $23.50 $15.30 $23.80

Level 2 with $25 Cancer Wellness/Health Screening

Premium

$16.45 $25.75 $16.75 $26.05

Level 2 with $50 Cancer Wellness/Health Screening

Premium

$17.90 $28.00 $18.20 $28.30

Level 2 with $75 Cancer Wellness/Health Screening

Premium

$19.75 $30.90 $20.05 $31.20

Level 2 with $100 Cancer Wellness/Health Screening

(13)

LEVEL 3

– Monthly Premiums - Composite Rates

Employee

/Spouse

One-Parent

Family

Two-Parent

Family

Level 3 WITHOUT Cancer Wellness/Health Screening

Premium

$20.00 $34.05 $20.45 $34.50

Level 3 with $25 Cancer Wellness/Health Screening

Premium

$21.45 $36.30 $21.90 $36.75

Level 3 with $50 Cancer Wellness/Health Screening

Premium

$22.90 $38.55 $23.35 $39.00

Level 3 with $75 Cancer Wellness/Health Screening

Premium

$24.75 $41.45 $25.20 $41.90

Level 3 with $100 Cancer Wellness/Health Screening

Premium

$26.65 $44.40 $27.10 $44.85

LEVEL 4

– Monthly Premiums - Composite Rates

Employee

/Spouse

One-Parent

Family

Two-Parent

Family

Level 4 WITHOUT Cancer Wellness/Health Screening

Premium

$28.95 $49.05 $29.55 $49.65

Level 4 with $25 Cancer Wellness/Health Screening

Premium

$30.40 $51.30 $31.00 $51.90

Level 4 with $50 Cancer Wellness/Health Screening

Premium

$31.85 $53.55 $32.45 $54.15

Level 4 with $75 Cancer Wellness/Health Screening

Premium

$33.70 $56.45 $34.30 $57.05

Level 4 with $100 Cancer Wellness/Health Screening

(14)

OPTIONAL RIDERS

Employee

/Spouse

One-Parent

Family

Two-Parent

Family

Specified Disease Hospital Confinement Rider

Premium

$1.25 $1.75 $1.25 $1.75

Initial Diagnosis of Cancer Rider (per $1,000)

Premium

$1.50 $2.50 $1.60 $2.60

Initial Diagnosis of Cancer Progressive Payment Rider

(15)

Plan 1

Hospital Confinement

Medical Treatment Pkg

$100 Health Screening

EE only

$1000

$1500

Daily HC

Enhance IC

17-49

$14.00

$19.70

$5.85

$4.90

50-59

$19.20

$27.05

$7.45

$5.15

60-64

$26.15

$36.95

$12.70

$5.55

65-75

$39.40

$55.25

$19.80

$7.85

EE/SP

$1000

$1500

Daily HC

Enhance IC

17-49

$38.15

$49.00

$11.10

$9.30

50-59

$47.95

$62.85

$14.15

$9.80

60-64

$61.15

$81.65

$24.15

$10.55

65-75

$87.50

$117.60

$37.60

$14.95

1 Parent

$1000

$1500

Daily HC

Enhance IC

17-49

$28.45

$36.15

$9.55

$5.45

50-59

$33.65

$43.50

$11.15

$5.70

60-64

$40.60

$53.40

$16.40

$6.10

65-75

$55.30

$73.35

$23.85

$8.45

2 Parent

$1000

$1500

Daily HC

Enhance IC

17-49

$45.90

$58.75

$14.80

$9.85

50-59

$55.70

$72.60

$17.85

$10.35

60-64

$68.90

$91.40

$27.85

$11.10

(16)

Plan 2

Hospital Confinement

Medical Treatment Pkg

$100 Health Screening

Tier 1 $500/Tier 2 $1000

EE only

$1000

$1500

Daily HC

Enhance IC

17-49

$29.40

$35.10

$5.85

$4.90

50-59

$37.65

$45.50

$7.45

$5.15

60-64

$47.30

$58.10

$12.70

$5.55

65-75

$67.00

$82.85

$19.80

$7.85

EE/SP

$1000

$1500

Daily HC

Enhance IC

17-49

$54.65

$65.50

$11.10

$9.30

50-59

$70.30

$85.20

$14.15

$9.80

60-64

$88.65

$109.15

$24.15

$10.55

65-75

$125.90

$156.00

$37.60

$14.95

1 Parent

$1000

$1500

Daily HC

Enhance IC

17-49

$42.40

$50.10

$9.55

$5.45

50-59

$50.65

$60.50

$11.15

$5.70

60-64

$60.30

$73.10

$16.40

$6.10

65-75

$81.30

$99.35

$23.85

$8.45

2 Parent

$1000

$1500

Daily HC

Enhance IC

17-49

$67.65

$80.50

$14.80

$9.85

50-59

$83.30

$100.20

$17.85

$10.35

60-64

$101.65

$124.15

$27.85

$11.10

(17)

Plan 3

Hospital Confinement

Medical Treatment Pkg

$100 Health Screening

Tier 1 $500/Tier 2 $1000

EE only

$1000

$1500

Daily HC

Enhance IC

17-49

$39.40

$45.10

$5.85

$4.90

50-59

$49.40

$57.25

$7.45

$5.15

60-64

$60.65

$71.45

$12.70

$5.55

65-75

$82.05

$97.90

$19.80

$7.85

EE/SP

$1000

$1500

Daily HC

Enhance IC

17-49

$73.65

$84.50

$11.10

$9.30

50-59

$92.60

$107.50

$14.15

$9.80

60-64

$114.00

$134.50

$24.15

$10.55

65-75

$154.55

$184.65

$37.60

$14.95

1 Parent

$1000

$1500

Daily HC

Enhance IC

17-49

$54.15

$61.85

$9.55

$5.45

50-59

$64.15

$74.00

$11.15

$5.70

60-64

$75.40

$88.20

$16.40

$6.10

65-75

$98.30

$116.35

$23.85

$8.45

2 Parent

$1000

$1500

Daily HC

Enhance IC

17-49

$88.40

$101.25

$14.80

$9.85

50-59

$107.35

$124.25

$17.85

$10.35

60-64

$128.75

$151.25

$27.85

$11.10

(18)

Colonial Life & Accident Insurance Company

Whole Life (IWL5000) Paid-Up at Age 70

Juvenile Premiums

Guaranteed Cash Value at Age 65

Issue Age Mo. Prem. Guar. Cash Value Mo. Prem. Guar. Cash Value Mo. Prem. Guar. Cash Value Mo. Prem. Guar. Cash Value Mo. Prem. Guar. Cash Value Mo. Prem. Guar. Cash Value Mo. Prem. Guar. Cash Value Mo. Prem. Guar. Cash Value Mo. Prem. Guar. Cash Value Mo. Prem. Guar. Cash Value 0 6.21 4,380 7.81 6,570 11.02 10,950 14.23 15,330 17.44 19,710 19.04 21,900 26.81 32,850 34.75 43,800 42.69 54,750 50.63 65,700 1 6.22 4,370 7.83 6,555 11.04 10,925 14.26 15,295 17.48 19,665 19.08 21,850 26.88 32,775 34.83 43,700 42.79 54,625 50.75 65,550 2 6.24 4,370 7.86 6,555 11.10 10,925 14.35 15,295 17.59 19,665 19.21 21,850 27.06 32,775 35.08 43,700 43.10 54,625 51.13 65,550 3 6.30 4,360 7.95 6,540 11.25 10,900 14.55 15,260 17.85 19,620 19.50 21,800 27.44 32,700 35.58 43,600 43.73 54,500 51.88 65,400 4 6.38 4,360 8.08 6,540 11.46 10,900 14.84 15,260 18.23 19,620 19.92 21,800 28.06 32,700 36.42 43,600 44.77 54,500 53.13 65,400 5 6.53 4,350 8.29 6,525 11.81 10,875 15.34 15,225 18.86 19,575 20.63 21,750 29.06 32,625 37.75 43,500 46.44 54,375 55.13 65,250 6 6.67 4,350 8.50 6,525 12.17 10,875 15.83 15,225 19.50 19,575 21.33 21,750 30.06 32,625 39.08 43,500 48.10 54,375 57.13 65,250 7 6.81 4,350 8.71 6,525 12.52 10,875 16.33 15,225 20.14 19,575 22.04 21,750 31.13 32,625 40.50 43,500 49.88 54,375 59.25 65,250 8 6.95 4,340 8.93 6,510 12.88 10,850 16.83 15,190 20.78 19,530 22.75 21,700 32.19 32,550 41.92 43,400 51.65 54,250 61.38 65,100 9 7.11 4,330 9.16 6,495 13.27 10,825 17.38 15,155 21.49 19,485 23.54 21,650 33.31 32,475 43.42 43,300 53.52 54,125 63.63 64,950 10 7.28 4,330 9.43 6,495 13.71 10,825 17.99 15,155 22.28 19,485 24.42 21,650 34.50 32,475 45.00 43,300 55.50 54,125 66.00 64,950 11 7.47 4,320 9.70 6,480 14.17 10,800 18.63 15,120 23.10 19,440 25.33 21,600 35.81 32,400 46.75 43,200 57.69 54,000 68.63 64,800 12 7.67 4,320 10.00 6,480 14.67 10,800 19.33 15,120 24.00 19,440 26.33 21,600 37.31 32,400 48.75 43,200 60.19 54,000 71.63 64,800 13 7.88 4,310 10.33 6,465 15.21 10,775 20.09 15,085 24.98 19,395 27.42 21,550 38.88 32,325 50.83 43,100 62.79 53,875 74.75 64,650 14 8.12 4,300 10.68 6,450 15.79 10,750 20.91 15,050 26.03 19,350 28.58 21,500 40.56 32,250 53.08 43,000 65.60 53,750 78.13 64,500 15 8.36 4,290 11.04 6,435 16.40 10,725 21.75 15,015 27.11 19,305 29.79 21,450 42.38 32,175 55.50 42,900 68.63 53,625 81.75 64,350 16 8.62 4,290 11.43 6,435 17.04 10,725 22.66 15,015 28.28 19,305 31.08 21,450 44.31 32,175 58.08 42,900 71.85 53,625 85.63 64,350 17 8.89 4,280 11.84 6,420 17.73 10,700 23.62 14,980 29.51 19,260 32.46 21,400 46.38 32,100 60.83 42,800 75.29 53,500 89.75 64,200

For cost and complete details, refer to policy forms ICC19-IWL5000J/IWL5000J and applicable state variations.

Exclusions and Limitations

If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit.

We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. Product may vary by state.

You will receive a policy summary or illustration (whichever is applicable in your state) when your policy is issued.

For costs and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.

© 2019 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

9-19 101952-1

(19)

Colonial Life & Accident Insurance Company

Whole Life (IWL5000) Paid-Up at Age 100

Non-Tobacco Premiums

Guaranteed Cash Value at Age 65*

Issue Age Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* 18 6.27 1,835 19 6.32 1,825 20 6.37 1,815 21 6.42 1,805 22 6.48 1,795 23 6.54 1,785 24 6.61 1,770 25 6.68 1,760 26 6.78 1,745 27 6.91 1,730 28 7.06 1,715 29 7.23 1,700 30 7.40 1,680 31 7.57 1,660 32 7.74 1,645 33 7.92 1,625 34 8.10 1,600 35 8.29 1,580 36 8.50 1,555 37 8.73 1,530 38 8.98 1,505 39 9.26 1,480 40 9.55 1,455 41 9.85 1,425 42 10.16 1,395 43 10.48 1,360 44 10.82 1,325 45 11.17 1,290 46 11.55 1,250 47 11.98 1,210 48 12.44 1,165 49 12.95 1,120 12.81 5,505 19.35 9,175 25.90 12,845 32.44 16,515 32.29 18,350 46.94 27,525 61.58 36,700 76.23 45,875 90.88 55,050 12.95 5,475 19.58 9,125 26.22 12,775 32.85 16,425 32.71 18,250 47.56 27,375 62.42 36,500 77.27 45,625 92.13 54,750 13.10 5,445 19.83 9,075 26.57 12,705 33.30 16,335 33.17 18,150 48.25 27,225 63.33 36,300 78.42 45,375 93.50 54,450 13.26 5,415 20.10 9,025 26.95 12,635 33.79 16,245 33.67 18,050 49.00 27,075 64.33 36,100 79.67 45,125 95.00 54,150 13.44 5,385 20.40 8,975 27.35 12,565 34.31 16,155 34.17 17,950 49.75 26,925 65.33 35,900 80.92 44,875 96.50 53,850 13.63 5,355 20.71 8,925 27.79 12,495 34.88 16,065 34.71 17,850 50.56 26,775 66.42 35,700 82.27 44,625 98.13 53,550 13.83 5,310 21.04 8,850 28.26 12,390 35.48 15,930 35.29 17,700 51.44 26,550 67.58 35,400 83.73 44,250 99.88 53,100 14.05 5,280 21.42 8,800 28.78 12,320 36.15 15,840 36.00 17,600 52.50 26,400 69.00 35,200 85.50 44,000 102.00 52,800 14.34 5,235 21.90 8,725 29.45 12,215 37.01 15,705 36.92 17,450 53.88 26,175 70.83 34,900 87.79 43,625 104.75 52,350 14.73 5,190 22.54 8,650 30.36 12,110 38.18 15,570 38.04 17,300 55.56 25,950 73.08 34,600 90.60 43,250 108.13 51,900 15.19 5,145 23.31 8,575 31.44 12,005 39.56 15,435 39.33 17,150 57.50 25,725 75.67 34,300 93.83 42,875 112.00 51,450 15.69 5,100 24.15 8,500 32.60 11,900 41.06 15,300 40.75 17,000 59.63 25,500 78.50 34,000 97.38 42,500 116.25 51,000 16.20 5,040 25.00 8,400 33.80 11,760 42.60 15,120 42.21 16,800 61.81 25,200 81.42 33,600 101.02 42,000 120.63 50,400 16.71 4,980 25.85 8,300 35.00 11,620 44.14 14,940 43.75 16,600 64.13 24,900 84.50 33,200 104.88 41,500 125.25 49,800 17.23 4,935 26.71 8,225 36.19 11,515 45.68 14,805 45.38 16,450 66.56 24,675 87.75 32,900 108.94 41,125 130.13 49,350 17.75 4,875 27.58 8,125 37.42 11,375 47.25 14,625 47.13 16,250 69.19 24,375 91.25 32,500 113.31 40,625 135.38 48,750 18.29 4,800 28.48 8,000 38.67 11,200 48.86 14,400 49.00 16,000 72.00 24,000 95.00 32,000 118.00 40,000 141.00 48,000 18.86 4,740 29.44 7,900 40.01 11,060 50.59 14,220 50.96 15,800 74.94 23,700 98.92 31,600 122.90 39,500 146.88 47,400 19.49 4,665 30.48 7,775 41.47 10,885 52.46 13,995 53.08 15,550 78.13 23,325 103.17 31,100 128.21 38,875 153.25 46,650 20.18 4,590 31.63 7,650 43.08 10,710 54.53 13,770 55.42 15,300 81.63 22,950 107.83 30,600 134.04 38,250 160.25 45,900 20.94 4,515 32.90 7,525 44.85 10,535 56.81 13,545 57.96 15,050 85.44 22,575 112.92 30,100 140.40 37,625 167.88 45,150 21.78 4,440 34.29 7,400 46.81 10,360 59.33 13,320 60.63 14,800 89.44 22,200 118.25 29,600 147.06 37,000 175.88 44,400 22.65 4,365 35.75 7,275 48.85 10,185 61.95 13,095 63.38 14,550 93.56 21,825 123.75 29,100 153.94 36,375 184.13 43,650 23.55 4,275 37.25 7,125 50.95 9,975 64.65 12,825 66.21 14,250 97.81 21,375 129.42 28,500 161.02 35,625 192.63 42,750 24.48 4,185 38.79 6,975 53.11 9,765 67.43 12,555 69.17 13,950 102.25 20,925 135.33 27,900 168.42 34,875 201.50 41,850 25.44 4,080 40.40 6,800 55.35 9,520 70.31 12,240 72.25 13,600 106.88 20,400 141.50 27,200 176.13 34,000 210.75 40,800 26.45 3,975 42.08 6,625 57.72 9,275 73.35 11,925 75.50 13,250 111.75 19,875 148.00 26,500 184.25 33,125 220.50 39,750 27.51 3,870 43.85 6,450 60.20 9,030 76.54 11,610 78.88 12,900 116.81 19,350 154.75 25,800 192.69 32,250 230.63 38,700 28.66 3,750 45.77 6,250 62.88 8,750 79.99 11,250 82.42 12,500 122.13 18,750 161.83 25,000 201.54 31,250 241.25 37,500 29.93 3,630 47.88 6,050 65.83 8,470 83.78 10,890 86.13 12,100 127.69 18,150 169.25 24,200 210.81 30,250 252.38 36,300 31.33 3,495 50.21 5,825 69.09 8,155 87.98 10,485 90.00 11,650 133.50 17,475 177.00 23,300 220.50 29,125 264.00 34,950 32.86 3,360 52.77 5,600 72.68 7,840 92.59 10,080 94.04 11,200 139.56 16,800 185.08 22,400 230.60 28,000 276.13 33,600

Note: Figures within the boxed area require Simplified Issue Level One (SI1) underwriting.

* 10th year cash value, if later than age 55

For complete details, refer to policy forms ICC19/IWL5000-100/IWL5000-100 and applicable state variations.

Exclusions and Limitations

If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit.

We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. Product may vary by state.

You will receive a policy summary or illustration (whichever is applicable in your state) when your policy is issued.

For costs and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.

9-19 101950-1

$150,000 $125,000

$75,000 $100,000 $5,000 $15,000 $25,000 $35,000 $45,000 $50,000

(20)

Whole Life (IWL5000) Paid-Up at Age 100

Non-Tobacco Premiums

Guaranteed Cash Value at Age 65*

Issue Age Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* 50 13.50 1,070 34.51 3,210 55.52 5,350 76.53 7,490 97.54 9,630 98.25 10,700 145.88 16,050 193.50 21,400 241.13 26,750 288.75 32,100 51 14.09 1,015 36.26 3,045 58.44 5,075 72.77 7,105 92.70 9,135 102.67 10,150 152.50 15,225 202.33 20,300 252.17 25,375 302.00 30,450 52 14.70 960 38.11 2,880 61.52 4,800 76.00 6,720 96.86 8,640 107.29 9,600 159.44 14,400 211.58 19,200 263.73 24,000 315.88 28,800 53 15.35 900 40.06 2,700 64.77 4,500 79.39 6,300 101.21 8,100 112.13 9,000 166.69 13,500 221.25 18,000 275.81 22,500 330.38 27,000 54 16.04 835 42.13 2,505 68.21 4,175 82.95 5,845 105.79 7,515 117.21 8,350 174.31 12,525 231.42 16,700 288.52 20,875 345.63 25,050 55 16.78 770 44.33 2,310 71.88 3,850 86.71 5,390 110.63 6,930 122.58 7,700 182.38 11,550 242.17 15,400 301.96 19,250 361.75 23,100 56 17.57 805 46.70 2,415 75.83 4,025 90.73 5,635 115.80 7,245 128.33 8,050 191.00 12,075 253.67 16,100 316.33 20,125 379.00 24,150 57 18.43 845 49.28 2,535 80.13 4,225 95.05 5,915 121.35 7,605 134.50 8,450 200.25 12,675 266.00 16,900 331.75 21,125 397.50 25,350 58 19.35 885 52.06 2,655 84.77 4,425 99.69 6,195 127.31 7,965 141.13 8,850 210.19 13,275 279.25 17,700 348.31 22,125 417.38 26,550 59 20.36 930 55.08 2,790 89.79 4,650 104.70 6,510 133.76 8,370 148.29 9,300 220.94 13,950 293.58 18,600 366.23 23,250 438.88 27,900 60 21.45 975 58.34 2,925 95.23 4,875 110.22 6,825 140.85 8,775 156.17 9,750 232.75 14,625 309.33 19,500 385.92 24,375 462.50 29,250 61 22.63 1,020 51.55 3,060 83.92 5,100 116.28 7,140 148.65 9,180 164.83 10,200 245.75 15,300 326.67 20,400 407.58 25,500 488.50 30,600 62 23.93 1,065 54.40 3,195 88.67 5,325 122.93 7,455 157.20 9,585 174.33 10,650 260.00 15,975 345.67 21,300 431.33 26,625 517.00 31,950 63 25.36 1,115 57.50 3,345 93.83 5,575 130.17 7,805 166.50 10,035 184.67 11,150 275.50 16,725 366.33 22,300 457.17 27,875 548.00 33,450 64 26.90 1,165 60.84 3,495 99.40 5,825 137.95 8,155 176.51 10,485 195.79 11,650 292.19 17,475 388.58 23,300 484.98 29,125 581.38 34,950 65 28.56 1,215 64.38 3,645 105.29 6,075 146.21 8,505 187.13 10,935 207.58 12,150 309.88 18,225 412.17 24,300 514.46 30,375 616.75 36,450 66 30.31 1,270 68.09 3,810 111.48 6,350 154.87 8,890 198.26 11,430 219.96 12,700 328.44 19,050 436.92 25,400 545.40 31,750 653.88 38,100 67 32.15 1,320 71.99 3,960 117.98 6,600 163.97 9,240 209.96 11,880 232.96 13,200 347.94 19,800 462.92 26,400 577.90 33,000 692.88 39,600 68 34.10 1,375 76.09 4,125 124.81 6,875 173.54 9,625 222.26 12,375 246.63 13,750 368.44 20,625 490.25 27,500 612.06 34,375 733.88 41,250 69 36.16 1,430 80.40 4,290 132.00 7,150 183.60 10,010 235.20 12,870 261.00 14,300 390.00 21,450 519.00 28,600 648.00 35,750 777.00 42,900 70 38.35 1,495 84.98 4,485 139.63 7,475 194.28 10,465 248.93 13,455 276.25 14,950 412.88 22,425 549.50 29,900 686.13 37,375 822.75 44,850 71 40.83 1,565 90.00 4,695 148.00 7,825 206.00 10,955 264.00 14,085 293.00 15,650 438.00 23,475 583.00 31,300 728.00 39,125 873.00 46,950 72 43.73 1,630 95.86 4,890 157.77 8,150 219.68 11,410 281.59 14,670 312.54 16,300 467.31 24,450 622.08 32,600 776.85 40,750 931.63 48,900 73 47.10 1,700 102.75 5,100 169.25 8,500 235.75 11,900 302.25 15,300 335.50 17,000 501.75 25,500 668.00 34,000 834.25 42,500 1,000.50 51,000 74 51.00 1,770 110.68 5,310 182.46 8,850 254.24 12,390 326.03 15,930 361.92 17,700 541.38 26,550 720.83 35,400 900.29 44,250 1,079.75 53,100 75 55.46 1,840 119.66 5,520 197.44 9,200 275.21 12,880 352.99 16,560 391.88 18,400 586.31 27,600 780.75 36,800 975.19 46,000 1,169.63 55,200 76 60.48 1,905 129.71 5,715 214.19 9,525 298.66 13,335 383.14 17,145 425.38 19,050 636.56 28,575 847.75 38,100 1,058.94 47,625 1,270.13 57,150 77 66.07 1,965 140.83 5,895 232.71 9,825 324.59 13,755 416.48 17,685 462.42 19,650 692.13 29,475 921.83 39,300 1,151.54 49,125 1,381.25 58,950 78 72.23 2,025 153.00 6,075 253.00 10,125 353.00 14,175 453.00 18,225 503.00 20,250 753.00 30,375 1,003.00 40,500 1,253.00 50,625 1,503.00 60,750 79 78.96 2,075 166.24 6,225 275.06 10,375 383.89 14,525 492.71 18,675 547.13 20,750 819.19 31,125 1,091.25 41,500 1,363.31 51,875 1,635.38 62,250

Note: Figures within the boxed area require Simplified Issue Level One (SI1) underwriting.

* 10th year cash value, if later than age 55

For complete details, refer to policy forms ICC19/IWL5000-100/IWL5000-100 and applicable state variations.

Exclusions and Limitations

If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit.

We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. Product may vary by state.

You will receive a policy summary or illustration (whichever is applicable in your state) when your policy is issued.

For costs and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.

9-19 101950-1

$150,000 $50,000 $75,000 $100,000 $125,000

(21)

Colonial Life & Accident Insurance Company

Whole Life (IWL5000) Paid-Up at Age 100

Tobacco Premiums

Guaranteed Cash Value at Age 65*

Issue Age Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* 18 7.90 2,270 17.69 6,810 27.48 11,350 37.27 15,890 47.06 20,430 51.46 22,700 75.69 34,050 99.92 45,400 124.15 56,750 148.38 68,100 19 8.09 2,260 18.26 6,780 28.44 11,300 38.61 15,820 48.79 20,340 51.79 22,600 76.19 33,900 100.58 45,200 124.98 56,500 149.38 67,800 20 8.29 2,245 18.86 6,735 29.44 11,225 40.01 15,715 50.59 20,205 52.13 22,450 76.69 33,675 101.25 44,900 125.81 56,125 150.38 67,350 21 8.50 2,235 19.49 6,705 30.48 11,175 41.47 15,645 52.46 20,115 52.21 22,350 76.81 33,525 101.42 44,700 126.02 55,875 150.63 67,050 22 8.71 2,220 20.13 6,660 31.54 11,100 42.96 15,540 54.38 19,980 52.29 22,200 76.94 33,300 101.58 44,400 126.23 55,500 150.88 66,600 23 8.93 2,205 20.79 6,615 32.65 11,025 44.50 15,435 56.36 19,845 52.42 22,050 77.13 33,075 101.83 44,100 126.54 55,125 151.25 66,150 24 9.16 2,190 21.48 6,570 33.79 10,950 46.11 15,330 58.43 19,710 52.58 21,900 77.38 32,850 102.17 43,800 126.96 54,750 151.75 65,700 25 9.38 2,175 22.13 6,525 34.88 10,875 47.63 15,225 60.38 19,575 52.83 21,750 77.75 32,625 102.67 43,500 127.58 54,375 152.50 65,250 26 9.52 2,160 22.56 6,480 35.60 10,800 48.65 15,120 61.69 19,440 53.33 21,600 78.50 32,400 103.67 43,200 128.83 54,000 154.00 64,800 27 9.67 2,140 23.00 6,420 36.33 10,700 49.67 14,980 63.00 19,260 54.17 21,400 79.75 32,100 105.33 42,800 130.92 53,500 156.50 64,200 28 9.81 2,120 23.44 6,360 37.06 10,600 50.69 14,840 64.31 19,080 55.25 21,200 81.38 31,800 107.50 42,400 133.63 53,000 159.75 63,600 29 9.97 2,100 23.90 6,300 37.83 10,500 51.77 14,700 65.70 18,900 56.63 21,000 83.44 31,500 110.25 42,000 137.06 52,500 163.88 63,000 30 10.15 2,080 24.44 6,240 38.73 10,400 53.02 14,560 67.31 18,720 58.21 20,800 85.81 31,200 113.42 41,600 141.02 52,000 168.63 62,400 31 10.37 2,060 25.10 6,180 39.83 10,300 54.57 14,420 69.30 18,540 60.00 20,600 88.50 30,900 117.00 41,200 145.50 51,500 174.00 61,800 32 10.62 2,035 25.85 6,105 41.08 10,175 56.32 14,245 71.55 18,315 62.00 20,350 91.50 30,525 121.00 40,700 150.50 50,875 180.00 61,050 33 10.88 2,010 26.64 6,030 42.40 10,050 58.15 14,070 73.91 18,090 64.21 20,100 94.81 30,150 125.42 40,200 156.02 50,250 186.63 60,300 34 11.14 1,985 27.43 5,955 43.71 9,925 59.99 13,895 76.28 17,865 66.63 19,850 98.44 29,775 130.25 39,700 162.06 49,625 193.88 59,550 35 11.40 1,955 28.20 5,865 45.00 9,775 61.80 13,685 78.60 17,595 69.25 19,550 102.38 29,325 135.50 39,100 168.63 48,875 201.75 58,650 36 11.65 1,925 28.95 5,775 46.25 9,625 63.55 13,475 80.85 17,325 72.04 19,250 106.56 28,875 141.08 38,500 175.60 48,125 210.13 57,750 37 11.90 1,895 29.70 5,685 47.50 9,475 65.30 13,265 83.10 17,055 74.96 18,950 110.94 28,425 146.92 37,900 182.90 47,375 218.88 56,850 38 12.15 1,865 30.45 5,595 48.75 9,325 67.05 13,055 85.35 16,785 77.96 18,650 115.44 27,975 152.92 37,300 190.40 46,625 227.88 55,950 39 12.40 1,830 31.20 5,490 50.00 9,150 68.80 12,810 87.60 16,470 81.08 18,300 120.13 27,450 159.17 36,600 198.21 45,750 237.25 54,900 40 12.67 1,795 32.01 5,385 51.35 8,975 70.70 12,565 90.04 16,155 84.38 17,950 125.06 26,925 165.75 35,900 206.44 44,875 247.13 53,850 41 12.99 1,760 32.96 5,280 52.94 8,800 72.91 12,320 92.89 15,840 87.96 17,600 130.44 26,400 172.92 35,200 215.40 44,000 257.88 52,800 42 13.38 1,720 34.13 5,160 54.88 8,600 75.63 12,040 96.38 15,480 91.96 17,200 136.44 25,800 180.92 34,400 225.40 43,000 269.88 51,600 43 13.85 1,680 35.55 5,040 57.25 8,400 78.95 11,760 100.65 15,120 96.42 16,800 143.13 25,200 189.83 33,600 236.54 42,000 283.25 50,400 44 14.41 1,635 37.24 4,905 60.06 8,175 82.89 11,445 105.71 14,715 101.29 16,350 150.44 24,525 199.58 32,700 248.73 40,875 297.88 49,050 45 15.06 1,590 39.18 4,770 63.29 7,950 87.41 11,130 111.53 14,310 106.46 15,900 158.19 23,850 209.92 31,800 261.65 39,750 313.38 47,700 46 15.77 1,540 41.30 4,620 66.83 7,700 92.37 10,780 117.90 13,860 111.92 15,400 166.38 23,100 220.83 30,800 275.29 38,500 329.75 46,200 47 16.52 1,490 43.55 4,470 70.58 7,450 97.62 10,430 124.65 13,410 117.67 14,900 175.00 22,350 232.33 29,800 289.67 37,250 347.00 44,700 48 17.30 1,430 45.90 4,290 74.50 7,150 103.10 10,010 131.70 12,870 123.67 14,300 184.00 21,450 244.33 28,600 304.67 35,750 365.00 42,900 49 18.12 1,375 48.36 4,125 78.60 6,875 108.85 9,625 139.09 12,375 129.88 13,750 193.31 20,625 256.75 27,500 320.19 34,375 383.63 41,250

Note: Figures within the boxed area require Simplified Issue Level One (SI1) underwriting.

* 10th year cash value, if later than age 55

For complete details, refer to policy forms ICC19/IWL5000-100/IWL5000-100 and applicable state variations.

Exclusions and Limitations

If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit.

We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. Product may vary by state.

You will receive a policy summary or illustration (whichever is applicable in your state) when your policy is issued.

For costs and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.

9-19 101951-1

$150,000 $75,000 $100,000 $125,000

$45,000 $50,000 $5,000 $15,000 $25,000 $35,000

(22)

Whole Life (IWL5000) Paid-Up at Age 100

Tobacco Premiums

Guaranteed Cash Value at Age 65*

Issue Age Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* Mo. Prem. Guar. Cash Value* 50 19.00 1,310 51.01 3,930 83.02 6,550 115.03 9,170 147.04 11,790 136.21 13,100 202.81 19,650 269.42 26,200 336.02 32,750 402.63 39,300 51 19.98 1,245 53.94 3,735 87.90 6,225 100.77 8,715 128.70 11,205 142.67 12,450 212.50 18,675 282.33 24,900 352.17 31,125 422.00 37,350 52 21.07 1,170 57.21 3,510 93.35 5,850 105.40 8,190 134.66 10,530 149.29 11,700 222.44 17,550 295.58 23,400 368.73 29,250 441.88 35,100 53 22.28 1,095 60.84 3,285 99.40 5,475 110.19 7,665 140.81 9,855 156.13 10,950 232.69 16,425 309.25 21,900 385.81 27,375 462.38 32,850 54 23.60 1,015 64.81 3,045 106.02 5,075 115.12 7,105 147.15 9,135 163.17 10,150 243.25 15,225 323.33 20,300 403.42 25,375 483.50 30,450 55 25.01 925 69.04 2,775 113.06 4,625 120.25 6,475 153.75 8,325 170.50 9,250 254.25 13,875 338.00 18,500 421.75 23,125 505.50 27,750 56 26.47 955 73.41 2,865 120.35 4,775 125.65 6,685 160.69 8,595 178.21 9,550 265.81 14,325 353.42 19,100 441.02 23,875 528.63 28,650 57 27.95 980 77.86 2,940 127.77 4,900 131.33 6,860 168.00 8,820 186.33 9,800 278.00 14,700 369.67 19,600 461.33 24,500 553.00 29,400 58 29.46 1,010 82.39 3,030 135.31 5,050 137.40 7,070 175.80 9,090 195.00 10,100 291.00 15,150 387.00 20,200 483.00 25,250 579.00 30,300 59 31.01 1,035 87.03 3,105 143.04 5,175 143.90 7,245 184.16 9,315 204.29 10,350 304.94 15,525 405.58 20,700 506.23 25,875 606.88 31,050 60 32.64 1,060 91.93 3,180 151.21 5,300 150.93 7,420 193.20 9,540 214.33 10,600 320.00 15,900 425.67 21,200 531.33 26,500 637.00 31,800 61 34.43 1,085 69.70 3,255 114.17 5,425 158.63 7,595 203.10 9,765 225.33 10,850 336.50 16,275 447.67 21,700 558.83 27,125 670.00 32,550 62 36.45 1,110 73.34 3,330 120.23 5,550 167.12 7,770 214.01 9,990 237.46 11,100 354.69 16,650 471.92 22,200 589.15 27,750 706.38 33,300 63 38.67 1,135 77.34 3,405 126.90 5,675 176.45 7,945 226.01 10,215 250.79 11,350 374.69 17,025 498.58 22,700 622.48 28,375 746.38 34,050 64 41.06 1,170 81.66 3,510 134.10 5,850 186.55 8,190 238.99 10,530 265.21 11,700 396.31 17,550 527.42 23,400 658.52 29,250 789.63 35,100 65 43.53 1,205 86.23 3,615 141.71 6,025 197.19 8,435 252.68 10,845 280.42 12,050 419.13 18,075 557.83 24,100 696.54 30,125 835.25 36,150 66 46.00 1,245 90.91 3,735 149.52 6,225 208.13 8,715 266.74 11,205 296.04 12,450 442.56 18,675 589.08 24,900 735.60 31,125 882.13 37,350 67 48.45 1,280 95.68 3,840 157.46 6,400 219.24 8,960 281.03 11,520 311.92 12,800 466.38 19,200 620.83 25,600 775.29 32,000 929.75 38,400 68 50.90 1,320 100.51 3,960 165.52 6,600 230.53 9,240 295.54 11,880 328.04 13,200 490.56 19,800 653.08 26,400 815.60 33,000 978.13 39,600 69 53.38 1,365 105.49 4,095 173.81 6,825 242.14 9,555 310.46 12,285 344.63 13,650 515.44 20,475 686.25 27,300 857.06 34,125 1,027.88 40,950 70 55.93 1,415 110.68 4,245 182.46 7,075 254.24 9,905 326.03 12,735 361.92 14,150 541.38 21,225 720.83 28,300 900.29 35,375 1,079.75 42,450 71 58.90 1,465 116.63 4,395 192.38 7,325 268.13 10,255 343.88 13,185 381.75 14,650 571.13 21,975 760.50 29,300 949.88 36,625 1,139.25 43,950 72 62.38 1,520 123.81 4,560 204.35 7,600 284.90 10,640 365.44 13,680 405.71 15,200 607.06 22,800 808.42 30,400 1,009.77 38,000 1,211.13 45,600 73 66.33 1,575 132.19 4,725 218.31 7,875 304.44 11,025 390.56 14,175 433.63 15,750 648.94 23,625 864.25 31,500 1,079.56 39,375 1,294.88 47,250 74 70.71 1,635 141.69 4,905 234.15 8,175 326.60 11,445 419.06 14,715 465.29 16,350 696.44 24,525 927.58 32,700 1,158.73 40,875 1,389.88 49,050 75 75.45 1,695 152.24 5,085 251.73 8,475 351.22 11,865 450.71 15,255 500.46 16,950 749.19 25,425 997.92 33,900 1,246.65 42,375 1,495.38 50,850 76 80.53 1,750 163.76 5,250 270.94 8,750 378.11 12,250 485.29 15,750 538.88 17,500 806.81 26,250 1,074.75 35,000 1,342.69 43,750 1,610.63 52,500 77 85.91 1,800 176.19 5,400 291.65 9,000 407.10 12,600 522.56 16,200 580.29 18,000 868.94 27,000 1,157.58 36,000 1,446.23 45,000 1,734.88 54,000 78 91.56 1,840 189.44 5,520 313.73 9,200 438.02 12,880 562.31 16,560 624.46 18,400 935.19 27,600 1,245.92 36,800 1,556.65 46,000 1,867.38 55,200 79 97.47 1,880 203.44 5,640 337.06 9,400 470.69 13,160 604.31 16,920 671.13 18,800 1,005.19 28,200 1,339.25 37,600 1,673.31 47,000 2,007.38 56,400

Note: Figures within the boxed area require Simplified Issue Level One (SI1) underwriting.

* 10th year cash value, if later than age 55

For complete details, refer to policy forms ICC19/IWL5000-100/IWL5000-100 and applicable state variations.

Exclusions and Limitations

If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit.

We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. Product may vary by state.

You will receive a policy summary or illustration (whichever is applicable in your state) when your policy is issued.

For costs and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.

9-19 101951-1

$150,000 $50,000 $75,000 $100,000 $125,000