Sample EBS Book by DEBSInsurance

Reimbursement Based on Class of Employees

Medical Expense Reimbursement Plans (105-c,h)

Class 1 of Employment

Class 1 Employees

Owner, President, CEO, CFO, COO

Class 2 Employees

Senior Vice President, Controller, Directors of Finance-HR

The employer may implement an employment class benefit to pay 100% of the monthly group Health, Dental, Vision, Disability, FSA, HSA benefits immediately or use an Employer Employee Employment Benefit Contract (EEEBC).

No Income to Class 1.

Class 2 of Employment

The employer may implement 100% of employee monthly premium and 50% of Dependent premium; then allow two (2) deductibles to be paid per family unit via MERP.

No Income to Class 2.

Class 3 of Employment

The employer may class monthly premium and one (1) deductible payment based on length of service as follows: Implement Tenure of Employment based on length of time of service before allowing employees a greater benefit.

Example:

Class 3 Employees

Managers, Foreman, Senior Technicians, Supervisors

Class 4 Employees

Senior Hourly Staff

Class 5 Employees

All other employees (Hourly & Part-time)

• 0-2 years; Standard

• 2-5 years; Employer pays 80% of EO premium, 60% of deductible and $10 reimbursement of Co-Pays.

• 5+ years; Employer pays 100% of employee premium, 50% of dependent premium, 75% of deductible, and $20 reimbursement of Co-pays.

No Income to Class 3.

Class 4 of Employment

The employer may implement some higher contribution than class five (5) based on discretion by use of Tenure of Employment based on length of time of service before allowing employees a greater benefit.

No Income to Class 4.

Class 5 of Employment

ACA complainant mandate only 9.83% rule.

Powerful sales tool option: Sales Person of the Year will get 100% of their benefits and claims paid.

Your Company MERP

Effective Date: ______

Your Company has implemented a Medical Expense Reimbursement Plan to assist each full-time employee or one dependent in paying a portion of their deductible.

Employer will reimburse the 1st $250 of the Deductible Then

Employer and Participant will split the remaining balance 50/50

When any employee or dependent has an eligible deductible claim, they will need to provide the following information to the HR department.

• Applicable EOB (explanation of benefits)

• Provider invoice/statement and proof of payment via paid receipt

• Or proof of a payment plan in place

EPO/POS Medical Benefits

Policy #:_______

Network Name:

Physician Co-Pay

Specialist Co-Pay

Prescription Co-Pays

Base Plan (EPO/POS)

$35 Co-Pay

$70 Co-Pay (Referral Required)

$10 Level 1/ $40 Level 2/

$70 Level 3/ 25% Level 4

Company will reimburse 3 Level 1 Co-Pays per family per month.

Annual Deductible (Calendar Year)

$5,000 In-Network

Employer pays first $250

Employee pays $2,375

Employer pays $2,375

Coinsurance 70/30 In-Network

Out of Pocket Max (Calendar Year)

Urgent Care Center

ER Facility

$6,500 In-Network

$100 Co-Pay

$1,000 Co-Pay, Deductible then 30%

In Hospital Deductible then 30%

Out Patient Surgery

Diagnostic Lab and X-Ray:

Complex Imaging (MRI, CT Scan)

Routine Adult & Child Wellness Exam

EPO/POS Plan

Employee Only

Spouse Rate

Children Rate

Spouse & Children Rate

Deductible then 30%

100% In-Network

You must see an In-Network provider.

Monthly Rate

$420

$420 Rating for each Employer-Employee Group Sponsored Benefit Plan is based on your census and claims. Each one Stands Alone.

$840

Diagnosed Wellness

Your Company will pay an Employee a $50 incentive for completing a Wellness Exam and will pay an Employee a $50 incentive for receiving a Flu/COVID-19 Vaccine/Booster.

MERP

Your Company has implemented a Medical Expense Reimbursement Plan to assist each full-time employee or one dependent in paying a portion of their deductible and prescription. Employer will reimburse 1st $250 of in network deductible and then will reimburse 50/50 till deductible is met per calendar year.

Disclaimer: The exact benefits provided by Carrier will be defined in the Carrier Summary of Benefits and Coverages and your benefit booklet provided by Carrier. The EBS provided by DEBS is for general information only.

Medical Benefits Policy #:_______

Network Name: Buy Up Plan #1 (PPO) Buy Up Plan #2 (HSA) All benefits listed below are In-Network benefits.

Primary Care Co-Pay

Specialist Co-Pay

Prescription Co-Pays

$30 Co-Pay Deductible then 30%

$40 Co-Pay Deductible then 30%

$10 Level 1/ $40 Level 2/

$70 Level 3/ 25% Level 4

Company will reimburse 3 Level 1 Co-Pays per family per month.

$3,000 In-Network $9,000 Out-of-Network

Annual Deductible (Calendar Year)

$7,000 In-Network $15,000 Out-of-Network Coinsurance

Employer pays first $250 Employee pays $1,375 Employer pays $1,375

Diagnosed Wellness

Your Company will pay an Employee a $50 incentive for completing a Wellness Exam and will pay an Employee a $50 incentive for receiving a Flu/COVID-19 Vaccine/Booster.

MERP

Dental Insurance Benefits

Policy #:_______

For Entire Summary of Dental DHMO Benefits, see Fee Schedule

If choosing the DHMO Dental Plan, please provide your DHMO Provider ID# in the space provided on your employee application.

Co-Pay

Vision Insurance Benefits Policy #:_______

$10 Exam; $10 Eyewear Frames $150 Allowance*

Lenses

Single Vision Paid In Full*

Lined Bifocal Paid In Full*

Lined Trifocal Paid In Full*

Lenticular Paid In Full*

Lens Options

Ultraviolet Coating

Polycarbonate (Child up to age 18)

Polycarbonate (Adult)

Standard Progressive

$0 Co-Pay

$33 Co-Pay

$55 Co-Pay

Scratch Resistant Coating $17 Co-Pay

Anti-Reflective Coating

$43 Co-Pay

Photochromic $47 Co-Pay

Contact Lenses

Fitting and Evaluation

Elective Lenses

Standard or Premium fit: Member receives 15% off Co-Pay will not exceed $60

$150 Allowance

Medically Required Paid In Full*

*After Co-Pay

Company Paid

Life Insurance Benefits

Policy #:_______

Basic Group Term Life and AD&D Insurance:

Your Company provides eligible full-time employees with $50,000 of Basic Group Term Life and Accidental Death and Dismemberment (AD&D) coverages

Employee Paid

Supplemental Life and AD&D Insurance:

Employees who want to supplement their group life and AD&D insurance benefits may purchase this additional coverage. When you enroll yourself and/or your dependents in this benefit, you pay the full cost through payroll deductions.

Employee: You can purchase coverage on yourself up to the lesser of 5 times your salary in $10,000 increments to a maximum of $500,000. Elections over $100,000 will require Evidence of Insurability and are subject to the carrier’s approval.

Spouse: You can purchase on your spouse up to 50% of the employee’s supplemental coverage amount in $5,000 increments to a maximum of $100,000. Elections over $25,000 will require Evidence of Insurability and are subject to carriers’ approval.

Basic Dependent Life Insurance: You can purchase a package for your spouse and child(ren). Coverage will be $5,000 for Spouse and $2,500 for every child

Things to keep in mind when making your Supplemental Life and AD&D insurance elections:

• You must select coverage for yourself to elect coverage for your spouse and children, except Basic Dependent Life Insurance.

• Your supplemental life and AD&D coverage elections are separate: you may elect different coverage amounts for each

• Any change requests to the supplemental life plans must be submitted to HR or DEBS for processing.

• Child coverage terminated at age 26.

Benefit Reductions

At age 70, providing you are still employed, your coverage will decrease to 65% of the benefit amount. It will decrease to 50% at age 75

Designating your Beneficiary:

As part of receiving this life insurance coverage, you must designate a beneficiary to receive benefits upon your death. Your beneficiary can be more than one person, but it is important that you keep this information up to date. Change in marital status or the death of a loved one may impact your beneficiary designation. The employee will automatically be designated as the beneficiary for spouse and child coverage.

You are advised not to name a minor as your beneficiary unless a guardian has been appointed and named in your Last Will of Testimony, or a Trust is used. Insurers generally will not make settlements directly to minors. Benefits payable to minors will be placed in a holding account until the state probates the estate, at which time proceeds will be awarded to the person whom the state appoints as the legal guardian if not specified in a Last Will of Testimony. You should consult with an attorney if you have questions.

Supplemental Life/AD&D Rate Calculations

Insurance Age: Your rate is based on your insurance age. To calculate your insurance age, subtract your year of birth from the year your coverage becomes effective. (ex: 2021 1975=46; you will fall under the 45-49 age band)

To Calculate Your Cost: Complete the section below using your coverage amount and rate (based on your insurance age).

Short Term Disability Policy

#:_______

(Employer Paid)

Elimination Period

Benefit Percentage

Minimum Weekly Benefit

Maximum

14-day accident, 14-day sickness

60% of Pre-Disability Earning

$20

$1,000 Benefit

Definition of Disability: Due to a sickness, or as direct result of accidental injury: The employee is receiving Appropriate Care and Treatment and Complying with the Requirements of such treatment and is unable to earn more than 80% of their pre-disability earning at their Own Occupation for any employer.

Pre-Existing Condition Limitation: Pre-existing condition means a sickness or accidental injury for which the employee received medical treatment, consultation, care, or services; took prescription medication or had medication prescribed in the 3 months before insurance or any increase in the amount of insurance under the certificate takes effect. We will not pay benefits, or any increase in benefit amount due to an elected increase in the amount of insurance for a disability that results for a Pre-existing condition. If the employee has been Actively at work for less than 12 consecutive months after the date their disability insurance or the elected increase in the amount of such insurance takes effect under the certificate.

Long Term Disability Policy #:_______

(Employer Paid)

Coverage Begins

Monthly Benefit Percentage

Minimum

Maximum

Own

Benefit

90 days or at the end of the STD maximum benefit period

60% of Pre-disability earnings

$100

$6,000

24 months from date of benefit

The later of your Normal Retirement Age as defined by Social Security or the period shown below:

When Can You Enroll and Change Benefits?

As a full-time employee of Your Company, you are eligible to participate in the benefit plan the 1st of the month following ___ days after your date of hire.

Eligible Dependents:

You may cover your eligible dependents under the benefit plan. Your eligible dependents may include

• Your legal spouse

• Your children up to age 26

• Your unmarried children over the age of 26, who are declared incapacitated.

• A child who is less than 26 and for whom the employee has received a Qualified Medical Child Support Order (QMCSCO) or National Medical Support Notice (NMSN) to provide coverage.

Spousal Documentation:

In order to add your legal spouse to the Health Plan, you must provide one of the required documents listed below:

• Copy of the Official State Marriage Certificate

• Official Certificate of Informal Marriage (if available) or Affidavit of Common Law Marriage

• If you have elected medical coverage for your legal spouse and they are eligible for coverage through his/her employer, you will be required to complete a Spouse Surcharge Affidavit

Qualified Change in Status

You can only change your coverage during the year when you experience a qualified change in states, such as:

• Marriage or Divorce

• Birth or adoption of a child

• A covered dependent no longer meets the plans definition of eligibility

• You become disabled

• Death of a spouse or dependent

• Change in employment status

• You or a covered dependent lose coverage through another plan

Any changes you make to your coverage must be made within thirty (30) days of the event. You will be required to provide supporting documentation and an updated enrollment form. Please contact DEBS or your HR department for more information.

Locate Providers on the Carrier Website

To access DocFind simply log on to the carrier’s website.

1. Select the type of provider you wish to find, such as Primary Care Physician (PCP), Specialist, Dentist, Medical Hospital, or Pharmacy.

2. Enter the geographic information for the area where you wish to find a participating provider.

3. Select your plan

4. If you choose, narrow your search by specialty, gender, languages spoken, hospital affiliation and/or name. Or request a list of all providers who match your geographic and plan requirements.

5. Done! You will be presented with a list of providers who match your criteria. You can obtain additional information about each provider by clicking on the “Provider Detail” link.

Flexible Spending Accounts (FSA)

Flexible Spending Accounts (FSA) provide you with an important tax advantage that will help you pay health care and dependent care expenses on a pre-tax basis. By anticipating your family’s health care and dependent care cost for the next year, you can actually lower your taxable income.

Employees have until March 15, 2026, to request reimbursement for eligible expenses incurred during the 2025 calendar year. Employees who participate in a Health Care Flexible Spending Account are allowed to roll over up to $660 of unused funds at the end of the calendar year. Without re-enrolling in healthcare reimbursement, the rollover is only available for one (1) year.

Health Care Reimbursement FSA

You can contribute up to a maximum IRS limit of $3,300 for 2025. Funds are reimbursed as deposited. You can use your account for a variety of eligible healthcare expenses incurred by you, your spouse, or your qualified dependents (pursuant to the definition of dependent in Internal Revenue Code 152). Some eligible expenses include unreimbursed out-of-pocket costs for: deductibles, copays, and coinsurance; dental services; vision care, included glasses or contacts; orthodontia expenses, etc. For a comprehensive list of eligible expenses, see IRS publication 502.

Dependent Care FSA

The Dependent Care FSA lets employees use pre-tax dollars towards qualified dependent care such as caring for children under the age of 12 or caring for elders. You decided how much to contribute, up to $5,000 per year per household. You may use the account for reimbursement for any dependent that lives with you and relies on you for more than half of his or her financial support. You must claim the person as a dependent on your federal income tax return. You may only be reimbursed for care that enables you to work, not occasional babysitters. If you are married, your spouse must also work, be a full-time student or be disabled. Eligible care includes daycare, before or after school care, and elder care for which you are responsible. Eligible dependents include children under 13, and disabled dependents of any age (such as your disabled spouse, older child, or parents)

Questions

Please contact Diversified Employee Benefit Services if you have any additional questions.

NOTE: You can either use a Dependent Care FSA or take the Dependent Care Tax Credit when you file your annual tax return, but not both. Please consult with your tax advisor to determine which option is best for you.

Legal Notices & Disclosures

NOTICE OF YOUR HIPPA SPECIAL ENROLLMENT RIGHTS

If you are declining enrollment for yourself and/or your dependents (including your spouse) because of other health insurance coverage or group health plan coverage, you may be able to enroll yourself and/or your dependents in this plan if you or your dependents lose eligibility for that other coverage or if the employer stops contributing towards you or your dependent’s coverage. However, you must request enrollment within 30 days after your other coverage ends or after the employer stops contributing towards the other coverage. In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and/or your dependent(s). However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

WOMEN’S HEALTH AND CANCER RIGHT ACT

On October 21, 1998, Congress passed the Women’s Health and Cancer Rights Act. This law requires group health plans that provide coverage for mastectomy to provide coverage for certain reconstructive services. These services include: Reconstruction of the breast upon which the mastectomy has been performed, surgery/reconstruction of the breast to produce a symmetrical appearance, prostheses, and physical complications during all stages of mastectomy, including lymphedemas. In addition, the plan may not interfere with a woman’s rights under the plan to avoid these requirements of the law. However, the plan may apply deductible and copays consistent with other coverage provided by the plan.

NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT OF 1996

Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the months, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans an issuer may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (96 hours)

PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs, but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov

If you or your dependents are already enrolled in Medicaid or CHIP, you can contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or call 1-877-KIDS-NOW or visit www.insurkidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you are not already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

Important Notice About Your Prescription Drug Coverage and Medicare Part D Notice

If you or any of your dependents are eligible for Medicare, or will soon become eligible for Medicare, please read this notice. If not, you can disregard this notice.

Medical Plan: Name and Carrier

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with your employer and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered and what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. Your Company has determined that the prescription drug coverage offered by the Employer is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decided to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th .

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decided To Join A Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current Your Company coverage will not be affected. Your current coverage pays for other health expenses in addition to prescription drug. If you enroll in a Medicare prescription drug plan, you and your eligible dependents will still be eligible to receive all of your current health and prescription benefits. This plan will coordinate with Part D coverage.

If you do decide to join a Medicare drug plan and drop your current Your Company coverage, be aware that you and your dependents may not be able to get this coverage back.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?

You should also note that if you drop or lose your current coverage with Your Company and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information About This Notice or Your Current Prescription Drug Coverage…

Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through your Employer changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverages…

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare Prescription drug coverage:

• Visit www.medicare.gov

Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help. Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048

Date: January 1, 2025

Contact-Position/Office: Stephen Geri, MGA, Diversified Employee Benefit Services Address: 2135 NW Military Hwy, San Antonio, TX 78213 Phone Number: 800-990-3427, ext. 113

CMS Form 10182-CC

Updated April 1, 2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instruction, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1805

Your Company

Enrollment Application 2025

I. Employee Information (PLEASE PRINT AND COMPLETE ALL INFORMATION)

II. Plan Options for Plan Year 2025-2026 (Please check all that apply.)

New Hires: Benefits will begin on the first of the month following ___ days of Employment.

III. Member Information (PLEASE PRINT AND COMPLETE ALL INFORMATION)

Indicate if you or your dependents are enrolling for medical, dental, vision, and life by completing the boxes below. Names of everyone applying for coverage

IV. Beneficiary Information (PLEASE PRINT AND COMPLETE ALL INFORMATION)

I AUTHORIZE MY EMPLOYER TO DEDUCT FROM MY EARNINGS THE APPLICABLE CONTRIBUTION(S) FOR COVERAGE ABOVE.

Employee Signature Date

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may be able to enroll yourself or your dependents in the future, provided that you request enrollment within 31 days after your other coverage ends. In addition, if you have new dependents as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself or your dependents in the future, provided that you request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.

I acknowledge that I have been given the opportunity to enroll in our Company Group Medical approved ACA plan available to myself and my dependents. I proclaim that I was not pressured or forced by employer/HR or the agent into waiting (declining ACA) coverage. If I have waived any ACA coverage offered to me or my dependent, my signature is evidence of this action.

Employee Signature Date

Your Company HIPAA Compliance Form

Section A: The Individual for whom this authorization is being requested. Please complete the following:

Section B: Physician, Hospital Provider Services, Pharmacies, Dentist & All other Medical Provider Services, the individual authorizes a DEBS employee to process, file, service, etc. any diagnosed claims.

This authorization will expire on:_____________________________________________( Insert Date or event) Describe the reason for the release or request of information: At the request of the individual

Section C: I Understand that:

• This authorization will expire on the date or event listed in Section B above.

• This authorization is voluntary.

• Payment, enrollment or eligibility for benefits for my health care will not be affected if I do not sign this form.

• I may revoke this authorization at any time by notifying in writing the company/individual listed in Section B from providing the PHI identified in this authorization, but if I do revoke this authorization, it won’t have any effect on any actions Diversified Employee Benefit Services took before they received the revocation.

• Information disclosed as a result of this authorization may no longer be protected by federal privacy laws and may be disclosed by the company or individual receiving the information.

• I should retain as my copy one of the duplicate authorization forms I received.

Section D: Signature

I hereby authorize the use or disclosure of the Protected Health Information as described in Section B for the individual listed in Section A.

Section E: If Section D is signed by a Personal Representative, please complete the information

Employee Name:

Benefit Contribution Worksheet

(Employer Copy)

Voluntary Life Insurance

Your pay period cost is based on your age and the amount of coverage you select. Refer to Rate Table for rates.

This brochure is designed for general information only and should not be construed as the contract(s). Please consult your benefit booklet for details or contact Diversified Employee Benefit Services, LLC. if you have any questions.

Employee Name:

Employee Social Security #:

Your Company

Election to Participate Form

Cafeteria Form (125-A)

Plan Year: through

Location:

As an eligible employee in the above plan, I acknowledge that I have received the Summary Plan Description. I have read the Summary Plan Description and understand the benefits available to me as well as the other rights and obligations which I have under the plan.

In accordance with my rights under the plan, I elect the following benefits and designate the following amounts for each benefit I have selected for the plan year specified above. The Employer and I agree that my cash compensation will be redirected by the amounts set forth below for each pay period and plan year (or during such portion of the year as remains after the date of this agreement.

Election for Benefits

On the appropriate benefit enrollment forms. I have enrolled for certain insurance coverages.

( ) In lieu of specified dollar amounts, I hereby elect the above specified insurance coverages and authorize salary redirections in the amounts of current premiums being charged. I understand that if my required contributions to pay premiums for the elected benefits are increased or decreased while this agreement remains in effect, my compensation redirection will automatically be adjusted to reflect that increase or decrease.

Other Terms and Conditions

I understand that:

• I cannot change or revoke any of my elections or this compensation redirection agreement at any time during the plan year unless I have a change in family status (including marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of employment of a spouse, change in my or my spouse’s employment status from full-time to part-time or from part-time to full-time, my spouse or I taking an unpaid leave of absence, a substantial change in my family’s health coverage due to a change in my spouse’s employer-sponsored health coverage, or such other events as the Plan Administrator determines will permit a change or revocation of an election.)

• The Plan Administrator may redirect or cancel my compensation redirection or otherwise modify this agreement in the event he believes it advisable in order to satisfy certain provisions of the Internal Revenue Code.

• The redirection in my cash compensation under this agreement shall be in addition to any reductions under other agreements or benefit programs maintained by my Employer.

• Any amounts that are not used during a plan year to provide benefits will be forfeited and may not be paid to me in cash or used to provide benefits specifically for me in a later plan year. (Exception: Medical Reimbursement Account (2) year rule)

• Prior to the first day of each plan year, I will be offered the opportunity to change my benefit elections for the following plan year. If I do not complete and return a new election form at that time. I will be treated as having elected to continue my benefit elections then in effect for the new plan year. In addition, this compensation redirection agreement will continue by its terms in the amount of the required contribution for the benefit options.

• If disability insurance is paid for on a pre-tax basis any benefits, I receive may be taxable.

• My Social Security benefits may be slightly reduced.

THIS AGREEMENT IS SUBJECT TO THE TERMS OF THE EMPLOYER’S CAFETERIA PLAN. AS AMENDED FROM TIME TO TIME IN EFFECT, SHALL BE GOVERNED BY AND CONSTRUED IN ACCORDANCE WITH APPLICABLE LAWS, SHALL TAKE EFFECT ASA SEALED INSTUMENT UNDER APPLICABLE LAWS. THIS REVOKES ANY PRIOR ELECTION AND COMPENSATION REDIRECTION AGREEMENT RELATING TO SUCH PLAN.

Employee Signature: X

I understand all benefit options available under the Plan

Date:

Election Not to Participate

( ) I elect not to participate in the Plan for the following plan year: through Employee Signature: X Date:

Your Company

Cafeteria Flexible Benefit Plan (125-C)

Salary Reduction Agreement

Name: SS#:

Address: City: State: Zip:

On separate benefit enrollment form(s), I have enrolled for certain insurance coverage’s and understand that an amount of equal to the amount of premiums for coverage(s) elected less any Non-elective Contributions allocable thereto will be withheld from my salary. I elect to receive (check coverage(s) desired):

Pre-Tax:  Health FSA Monthly $____________________  Health FSA Annually $____________________

Under the Flexible Benefit Plan as elected in the Pre-tax column. Any previous election and Salary Reduction Agreement under the Flexible Benefit Plan relation to the same benefit as selected above is hereby revoked.

Waiver of Pre-Tax Benefit under the Flexible Benefit Plan [Check box if applicable]

 I elect to waive all pre-tax benefits under the Flexible Benefits Plan. Except for a Change in Status, I understand that I cannot elect pre-tax benefits until the next Anniversary date, and an After-tax coverages shall be outside the plan.

I have read and agree to the terms of participation set forth on this form.

and agreed

Your Company HSA Plan

Salary Reduction Agreement

Name: SS#:

Address: City: State: Zip:

Contributions

$1,000 per individual age 55 older

I have read and agree to the terms of participation set forth on this form.

Employee’s Signature Date

Accepted and agreed to Plan Administrator’s Signature Date Diversified Employee Benefit Services, LLC

Employee Name:

Benefit Contribution Worksheet

(Employee Copy)

If you choose

Voluntary Life Insurance

Your pay period cost is based on your age and the amount of coverage you select. Refer to Rate Table for rates.

Important Contact Information

Broker Information

Diversified Employee Benefit Services, LLC 2135 NW Military Hwy, San Antonio, TX 78213 (210) 558-3377 Toll Free: (800) 990-3427 (210)558-3332 Fax

Karen Geri, Agent – kgeri@debsinsurance.com

For all service issues: Afton Smith-Esparza – asmith@debsinsurance.com

Carrier Information

Policy #: Member Services: