For Individuals Purchasing Benefits by Paul Sweany

For Individuals Purchasing Benefits PT Level 1 or 2

Employee Name:

______________________________________ EE ID__________

Pursuant to the terms of the C&K Market, Inc., Cafeteria Plan, I make the following Cafeteria Plan elections and agree to contribute as follows: A. Wellness Credits you are eligible to receive for Quest Screening. Note: You must choose to enroll in a health plan to receive this credit. If you choose PPO coverage the credit will reduce your monthly premium. If you choose HDHP coverage the credit amount will be added to your HSA per month. A1.

A2. MONTHLY

Your Wellness Credits

$0.00 MONTHLY

Your Spouse’s Wellness Credits

B. Health Coverage – Choose from one of the three options below. This coverage includes: Health, Prescription, and Vision Coverage. Please note for Prescription coverage, if you choose PPO, you will have a $50 deductible per individual. If you choose an HDHP option the Prescription and Medical deductibles are combined. The coverage also includes, Short-Term Disability ($100.00 per week), $10,000 Employee Term Life, $2,500 Dependent Term Life. Please Note: Life coverage is reduced for those over the age of 65. Mark B1. I Choose PPO Health Coverage – $400/$800 Individual or Family Embedded Deductible Current PPO Enrollees may update as needed; No One Only Mark Only One Enter This Amount New PPO participants accepted. EE EE+1 EE+2

$561.00 $1,042.00 $1,461.00

Enter Wellness Credits from A1 and A2 if choosing EE+1 or EE+2 Please Note: Only enter value from A1 if you are choosing Individual Coverage

MONTHLY

Subtract Wellness Credit from monthly premium and enter in Box B1.

B2. I Choose HDHP #1 – $1,500/$3,000 Single Participant or Family Combined Mark Only One EE EE+1 EE+2

Enter This Amount $526.00 $962.00 $1,344.00

B2. MONTHLY

B3. I Choose HDHP #2 – $3,000/$6,000 Individual or Family Embedded Deductible Mark Only One EE EE+1 EE+2

Enter This Amount $416.00 $755.00 $1,052.00

B3. MONTHLY

Enter your amount from Box B1, B2, or B3 here

MONTHLY

HSA IS AVAILABLE IF YOU ARE ENROLLED EXCLUSIVELY IN A HIGH-DEDUCTIBLE HEALTH PLAN C. Health Savings Account (HSA)1 Use this worksheet to determine your monthly HSA contribution Wellness Credits per month Enter Wellness Credits from A1 & A2 above if you are choosing EE+1 or EE+2 coverage. Only enter A1 if you choose Individual coverage. My Contribution per month Enter this amount in Box C for your monthly contribution.

Company will match your monthly contribution up to the following amounts for the family size enrolled in Medical = $25 Individuals = $37.50 EE+1 = $50 EE+2

TOTAL Multiply by number of months eligible for.

X 12

Annual Amount before Prefund Company Prefund Amount Please enter amount from list below based on family size coverage you chose: EE=$400.00 EE+1=$600.00 EE+2=$800.00 TOTAL Annual Contribution cannot exceed IRS maximums for 2013: $3,250 Individual $6,450Family

C. MONTHLY

Please provide your physical street address. It is a requirement to open an account with US Bank. It will not be used for mailing purposes. __________________________________________________ Physical address, City, State, Zip Code Mark this box if you are not eligible to participate in an HSA (covered by a low deductible health plan, eligible for Medicare coverage, etc.)

FSA ONLY AVAILABLE IF NOT PARTICIPATING IN AN HDHP/HSA D. Medical Reimbursement (FSA)2

D. MONTHLY

Choose between $0 - $208.33 ($2,500 maximum per year)

E. Dental Coverage

Family Size EE EE+1 EE+2

Enter This Amount $44.00 $83.00 $125.00

E. MONTHLY

F. Child / Dependent Care Reimbursement Account Choose between $0 - $416.67 $5,000 maximum per year OR $2,500 maximum per year if married filing separately

F. MONTHLY

G. Term Life Insurance Premiums vary based on age and tobacco use status. The Benefit Counselor with Colonial Life can share the options and costs available to you specifically.

I. MONTHLY

Please note: $50,000 is only available if you do not enroll in Health Coverage. A Standard Life Insurance application will be sent to you if you newly choose term life. Life Coverage is reduced for those employees over the age of 70.

To determine your per pay period cost, fill in the lines at right using the amounts you entered on pages 1 and 2.

Health

HSA

FSA

Dental

Childcare

Life Ins.

Total Monthly Cost of Benefits Selected Divide by 2 for Per Pay Period Reduction

I have also been offered to participate in the Voluntary Benefits offered through Unum and Colonial Life. Subject to approval by these carriers, I have elected: Check here if applied

Benefit

Per Paycheck Deduction

Long Term Disability Short Term Disability Accident Coverage Group Term Life

In addition to the Election Form generated by Colonial Life and electronically signed by me, I acknowledge and understand the following: 1. Except for HSA contributions, this election is irrevocable for the stated plan year unless I have an event that permits an election change as described in the Cafeteria Plan. 2. The employer will reimburse me for qualified expenses out of my medical reimbursement and/or dependent care accounts as defined in the plan with satisfactory proof of expense. 3. If my contributions to my medical reimbursement and/or dependent care accounts for the plan year are greater than the amount of my qualified expenses, I will forfeit the excess amount. 4. This election revokes any prior election I have made. 5. If you do not submit your election form to the Human Resources department prior to the pay period in which you are eligible for benefits, any payroll reductions you are subject to, will be prorated for the plan year and your per month charge will be increased accordingly. 6. If you make false representations about your participation in the C&K Market, Inc. Health Plan (the “Plan”), the Plan has the right to terminate coverage permanently for you and all of your eligible dependents. The Plan may seek reimbursement from you of all claims paid as a result of the misrepresentation and may pursue legal action against you. In addition, you will be required to reimburse C&K Market, Inc. for the value of any premiums paid by them for coverage of any ineligible dependents in the Plan. Such misrepresentation may also result in disciplinary action up to and including termination of employment. False representation includes, but is not limited to, adding a dependent who is ineligible (for instance, adding a spouse when you aren’t married or adding a child who doesn’t meet the plan qualifications of an eligible dependent) or permitting another individual to use your medical benefits card. Signature of Participant

Participant Printed Name

Date

Emp 6/16949

WAIVER I understand the tax advantages of the Cafeteria Plan, but I decline to participate.

Signature of Participant

Participant Printed Name

Date

Special Note regarding Health Savings Accounts

See the brochure provided by U.S. Bank for a discussion of expenses that may be considered eligible and ineligible. In addition, copies of IRS Publication 969 entitled Health Savings Accounts and Other Tax-Favored Health Plans are available on the web at http://www.irs.gov. 2

Special Note regarding Flexible Spending Accounts A discussion of expenses that may be considered eligible and ineligible is contained in IRS Publication 502 entitled Medical and Dental Expenses. Copies of IRS Pub. 502 are available on the web at http://www.irs.gov. Caution: Certain information in IRS Pub. 502 may not be applicable, since some of the laws governing Medical Reimbursement Accounts are different from the laws governing medical expense deductibility. One difference is that premiums for health insurance are never reimbursable from Medical Reimbursement Accounts.