Your Age:    
Your current base salary:   $ per year
Did you elect option A:         
The number of multiples (option B):        0     1     2      3      4      5
The number of multiples (option C):        0     1     2      3      4      5

Option A Option B Option C
Amount of coverage:$     $     $      
Cost per pay period:$     $     $      
Base Coverage:$