Spreadsheet: louise_kitchen__22821__Hardship Rates
Sheet: Citigroup Rate Chart

 |  |  | MEDICAL PLANS |  |  |  |  |  | Dental Plans |  |  | Vision Plan |  | AD&D |  |  | LIFE INSURANCE |  |  |  |  | LTD |  | EMPLOYEE COSTS
 | [NAME] |  | Point-of-Service Out of Area CIGNA International | Health Plan 2000 | HMO A | HMO B | HMO C |  | MetDen 75/Cigna International | Cigna DHMO |  | [NAME] |  | AD&D Per $10,000 of Coverage | AD&D Per $10,000 of Coverage |  | Employee Life Insurance Per $1,000 | Spouse Life Insurance Per $1,000 | Dependent Life Insurance |  |  | LTD Monthly Premium Per $1000 |  | Items 1, 6, 8, 9,  11, 14 | Items 1, 6, 8, 10,  11, 12, 13, 14 | Annual Cost | Benefit Cost as a Percentage of Salary
 | EO |  | Employee Only-EO |  |  |  |  |  | EO |  |  | 1 Person |  | EO | EF |  | EE | SP | DEP |  |  | 60% |  |  |  | Column Z
 |  |  |  |  |  |  |  |  |  |  |  |  |  | 10000 |  |  | 0.05 | 0.05 |  |  |  | 1000
 | Item |  | 1 | 2 | 3 | 4 | 5 |  | 6 | 7 |  | 8 |  | 9 | 10 |  | 11 | 12 | 13 |  |  | 14 |  | Monthly | Monthly
24000 | <25,000 |  | 40 | 30 | 23 | 32 | 35 |  | 14 | 6 |  | 5.4 |  |  |  |  |  |  | 0.84
25000 | $25,000-$39,999 |  | 47 | 36 | 29 | 38 | 42 |  | 14 | 6 |  | 5.4 |  |  |  |  |  |  | 0.84
40000 | $40,000-$59,999 |  | 58 | 43 | 37 | 46 | 51 |  | 14 | 6 |  | 5.4 |  |  |  |  |  |  | 0.84
60000 | $60,000-$79,999 |  | 70 | 47 | 47 | 57 | 63 |  | 14 | 6 |  | 5.4 |  |  |  |  |  |  | 0.84
80000 | $80,000-$99,999 |  | 83 | 58 | 58 | 69 | 75 |  | 14 | 6 |  | 5.4 |  |  |  |  |  |  | 0.84
100000 | $100,000-$149,000 |  | 99 | 67 | 70 | 82 | 90 |  | 14 | 6 |  | 5.4 |  |  |  |  |  |  | 0.84
150000 | $150,000-$199,000 |  | 129 | 90 | 94 | 111 | 120 |  | 14 | 6 |  | 5.4 |  |  |  |  |  |  | 0.84
200000 | $200,000-$299,999 |  | 139 | 95 | 99 | 117 | 126 |  | 14 | 6 |  | 5.4 |  |  |  |  |  |  | 0.84
300000 | $300,000-$499,999 |  | 146 | 99 | 103 | 122 | 132 |  | 14 | 6 |  | 5.4 |  |  |  |  |  |  | 0.84
500000 | >500,000 |  | 152 | 104 | 108 | 128 | 138 |  | 14 | 6 |  | 5.4 |  |  |  |  |  |  | 0.84
 | ES |  | Employee & Spouse/Domestic Partner-ES |  |  |  |  |  | ES |  |  | 2 People |  | EO | EF |  | EE | SP | DEP |  |  | 60%
24000 | <25,000 |  | 74 | 57 | 45 | 63 | 67 |  | 30 | 13 |  | 9.72 |  |  |  |  |  |  | 0.84
25000 | $25,000-$39,999 |  | 92 | 70 | 57 | 74 | 82 |  | 30 | 13 |  | 9.72 |  |  |  |  |  |  | 0.84
40000 | $40,000-$59,999 |  | 109 | 86 | 74 | 93 | 102 |  | 30 | 13 |  | 9.72 |  |  |  |  |  |  | 0.84
60000 | $60,000-$79,999 |  | 138 | 94 | 94 | 113 | 124 |  | 30 | 13 |  | 9.72 |  |  |  |  |  |  | 0.84
80000 | $80,000-$99,999 |  | 166 | 115 | 115 | 137 | 152 |  | 30 | 13 |  | 9.72 |  |  |  |  |  |  | 0.84
100000 | $100,000-$149,000 |  | 196 | 134 | 140 | 165 | 179 |  | 30 | 13 |  | 9.72 |  |  |  |  |  |  | 0.84
150000 | $150,000-$199,000 |  | 248 | 180 | 187 | 222 | 234 |  | 30 | 13 |  | 9.72 |  |  |  |  |  |  | 0.84
200000 | $200,000-$299,999 |  | 286 | 189 | 196 | 233 | 246 |  | 30 | 13 |  | 9.72 |  |  |  |  |  |  | 0.84
300000 | $300,000-$499,999 |  | 280 | 198 | 206 | 244 | 257 |  | 30 | 13 |  | 9.72 |  |  |  |  |  |  | 0.84
500000 | >500,000 |  | 293 | 207 | 215 | 255 | 269 |  | 30 | 13 |  | 9.72 |  |  |  |  |  |  | 0.84
 | EC |  | Employee & Children-EC |  |  |  |  |  | EC |  |  | 2 People |  | EO | EF |  | EE | SP | DEP |  |  | 60%
24000 | <25,000 |  | 70 | 52 | 40 | 55 | 61 |  | 26 | 11 |  | 9.72 |  |  |  |  |  |  | 0.84
25000 | $25,000-$39,999 |  | 85 | 65 | 52 | 68 | 76 |  | 26 | 11 |  | 9.72 |  |  |  |  |  |  | 0.84
40000 | $40,000-$59,999 |  | 104 | 77 | 67 | 83 | 92 |  | 26 | 11 |  | 9.72 |  |  |  |  |  |  | 0.84
60000 | $60,000-$79,999 |  | 126 | 85 | 85 | 103 | 113 |  | 26 | 11 |  | 9.72 |  |  |  |  |  |  | 0.84
80000 | $80,000-$99,999 |  | 149 | 104 | 104 | 124 | 135 |  | 26 | 11 |  | 9.72 |  |  |  |  |  |  | 0.84
100000 | $100,000-$149,000 |  | 178 | 121 | 126 | 148 | 162 |  | 26 | 11 |  | 9.72 |  |  |  |  |  |  | 0.84
150000 | $150,000-$199,000 |  | 232 | 162 | 169 | 200 | 216 |  | 26 | 11 |  | 9.72 |  |  |  |  |  |  | 0.84
200000 | $200,000-$299,999 |  | 250 | 171 | 178 | 211 | 227 |  | 26 | 11 |  | 9.72 |  |  |  |  |  |  | 0.84
300000 | $300,000-$499,999 |  | 263 | 178 | 185 | 220 | 238 |  | 26 | 11 |  | 9.72 |  |  |  |  |  |  | 0.84
500000 | >500,000 |  | 274 | 187 | 194 | 230 | 248 |  | 26 | 11 |  | 9.72 |  |  |  |  |  |  | 0.84
 | EF |  | Employee & Family-EF |  |  |  |  |  | EF |  |  | Family |  | EO | EF |  | EE | SP | DEP |  |  | 60%
24000 | <25,000 |  | 97 | 77 | 61 | 84 | 91 |  | 53 | 18 |  | 14.6 |  |  |  |  |  |  | 0.84
25000 | $25,000-$39,999 |  | 117 | 93 | 74 | 101 | 110 |  | 53 | 18 |  | 14.6 |  |  |  |  |  |  | 0.84
40000 | $40,000-$59,999 |  | 143 | 112 | 93 | 123 | 131 |  | 53 | 18 |  | 14.6 |  |  |  |  |  |  | 0.84
60000 | $60,000-$79,999 |  | 179 | 118 | 118 | 153 | 166 |  | 53 | 18 |  | 14.6 |  |  |  |  |  |  | 0.84
80000 | $80,000-$99,999 |  | 215 | 142 | 142 | 186 | 200 |  | 53 | 18 |  | 14.6 |  |  |  |  |  |  | 0.84
100000 | $100,000-$149,000 |  | 252 | 167 | 172 | 216 | 234 |  | 53 | 18 |  | 14.6 |  |  |  |  |  |  | 0.84
150000 | $150,000-$199,000 |  | 320 | 230 | 235 | 291 | 312 |  | 53 | 18 |  | 14.6 |  |  |  |  |  |  | 0.84
200000 | $200,000-$299,999 |  | 346 | 242 | 247 | 306 | 328 |  | 53 | 18 |  | 14.6 |  |  |  |  |  |  | 0.84
300000 | $300,000-$499,999 |  | 362 | 253 | 259 | 320 | 343 |  | 53 | 18 |  | 14.6 |  |  |  |  |  |  | 0.84
500000 | >500,000 |  | 378 | 265 | 270 | 335 | 359 |  | 53 | 18 |  | 14.6 |  |  |  |  |  |  | 0.84
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | AVG