MID-AMERICA ASSOCIATES

Transcription

1 MID-AMERICA ASSOCIATES FULLY FUNDED AND HSA SELF INSURED HEALTH PLANS Employer Application by MID-AMERICA Patient Protection & Affordable Care Act Employer Health Plan Options for Businesses with up to 100 Employees

2 FULLY FUNDED EMPLOYER APPLICATION EMPLOYER GROUP INFORMATION The Employer Plan Requested Coverage Deductible Accumulates on: : o Calendar Year o Plan Year FIRM NAME (legal name) Tax ID# SIC Code Address City State Zip Code NOTE: If multiple locations are to be identified separately, please list here: /Address City State Zip Code Employer Contact Contact Title Contact Phone Contact Fax Contact Address Business is a o LLC Nature of Business Total Number of Employees - including employees NOT enrolled for Coverage o Partnership o Corporation Full Time Part Time Seasonal New employees are covered on the first of the month following: o 30 days o 60 days o 90 days Coverage begins on 91st day. Coverage Reinstatement Provision: None 1st of month following: 30 days 60 days other ( not to exceed 6 months) from date of temporary lay-off. Indicate the percentage of employees costs which the employer will pay for of Worker s Compensation Carrier (answer #6 below) employees % and dependents % Has the employer had Group Medical Coverage for the past 12 months? Carrier, Address and Phone Number o Yes o No If yes, attach a copy of the most recent billing statement. Employer is: o Single employer, under 50 total employees. Employer files 1094-B Transmittal of Health Coverage Information Return. o A Large Employer over 50 employees and/or employer under common ownership with over 50 combined employees. Employer files 1094-C Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Return. EMPLOYER GROUP PLAN INFORMATION 1. What is the renewal date of your current group health plan?: 2. Is coverage actively in force? o Yes o No If no, provide date and reason for coverage lapse: 3. Are any employees or dependents applying for coverage currently disabled, hospital confined, or not working full-time at least 30 hours per week? o Yes o No If yes, attach written details. 4. Is any employee currently on temporary lay-off, disability, leave of absence or family medical leave? o Yes o No If yes, attach written details. 5. Is any person currently receiving or eligible for continuation of benefits pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)? o Yes o No If yes, attach written details and a copy of each COBRA election form including the name of the current COBRA administrator. 6. Are all employees applying for coverage currently covered under Worker s Compensation? o Yes o No Provide names of applicants not covered under Worker s Compensation. 7. For Employers with fewer than 20 total employees, Medicare is primary payer. Active employees or spouses eligible for Medicare must be enrolled for Medicare Parts A & B. Are any applicants now applying for coverage eligible for Medicare? o Yes o No If yes, provide copy of Medicare ID card. If applicant is Medicare eligible and not enrolled in Parts A & B, benefits are reduced. Employer agrees to notify affected applicants that Medicare enrollment is required upon effective date of group coverage. 8. Are all eligible full-time employees offered coverage under this plan? o Yes o No If no, are employees provided coverage under another Plan? o Yes o No If yes, how many employees are covered under another health plan sponsored by Employer? Explain reason for maintaining 2 or more separate group health plans: If more than one group health plan, do employee s have option to elect this plan at Open Enrollment? o Yes o No 9. Open Enrollment allows for a coverage effective date on the Plan Anniversary when enrolled timely. Does Employer require an alternate Open Enrollment Period? o Yes o No If yes, define Employer s Open Enrollment Period:

3 MID-AMERICA EMPLOYER PLAN COVERAGE REQUESTED Standard Base Plan Deductible (2x Family) o $250 o $500 o $750 o $1,000 o $1,500 o $2,000 o $2,500 o $3,000 o $4,000 o $5,000 Out-of network = 2 times deductible elected Co-Insurance (Out-of-Network In Parenthesis) o 100% (50%) o 90% (50%) o 80% (50%) o 70% (50%) HEALTH SAVINGS ACCOUNTS (HSA s) PLAN DESIGN OPTIONS Stop Loss (2x Family) o $5,000 o $10,000 o NONE* Doctors Office Visit Co-Pay (Not Subject To Deductible) o $10 o $20 o $30 o $40 o $50 Does not apply to Health Savings Account (HSA) Plan options. Optional 100% Diagnostic Lab/X-Ray Coverage (Non-HSA Plans) o Yes o No Healthy Choice (Plan Year Deductible/Co-Insurance Accumulation Only) o Yes o No Prescription Drug Card Benefit: o 5/15/30/20% o 10/20/40/20% o 15/30/50/20% o 20/40/80/20% o 25/50/100/20% o 30/60/120/20% Optional Pediatric Dental (Subject to Medical Plan Deductible and Co-Insurance) o Yes o No Health Savings Account (HSA) Deductible: o $1,500 o $2,000 o $2,500 o $3,000 o $4,000 o $5,000 Health Savings Account Co-Insurance (Out-of-Network In Parenthesis) o 100% (50%) o 80% (50%) Select Deductible/Co-insurance Accumulation Type: Calendar Year Plan Year Health Savings Account Stop Loss (2x Family) o $5,000 o $10,000 o NONE* *None = Annual HSA maximum out of pocket limit (deductible plus coinsurance). Optional Pediatric Dental (Subject to Medical Plan Deductible and Co-Insurance) o Yes o No Plans are subject to the rules and regulations of PPACA. Individual and family maximum out-of-pocket will not exceed the PPACA maximum. SUMMARY OF MONTHLY COSTS Attach plans most recent quote. Final administrative fees, premiums and the level monthly claim fund costs will be based upon the data of employees and dependents actually enrolled. PLAN IMPLEMENTATION CHECKLIST PLEASE VERIFY EACH ITEM BELOW and make certain all items are included with plan submission. o COMPLETED EMPLOYER PLAN APPLICATION AND SIGNED AGREEMENT. o PRODUCER S CONTRACT & COPY OF LICENSE (with first group submission.) o COMPLETED EMPLOYEE APPLICATIONS (Including those in their waiting period, on COBRA Continuation, or in COBRA election period and those electing Life/AD&D only.) Late applications submitted after group effective date will not be accepted. o FOR THOSE WAIVING COVERAGE, APPLICATION FORMS WITH WAIVER SECTION COMPLETED AND SIGNED. o MOST RECENT PRIOR CARRIER BILLING WITH EFFECTIVE DATE OF EACH ENROLLEE. (Please verify that there is an enrollment or a waiver for each individual listed on the prior carrier bill.) o WAGE & TAX QUARTERLY REPORT. o EMPLOYER CENSUS DECLARATION. o ORIGINAL GROUP QUOTE RECEIVED FROM MID-AMERICA ASSOCIATES. o FIRST MONTH S ADMINISTRATIVE FEES, PREMIUMS AND THE LEVEL MONTHLY CLAIM FUND COSTS PAYABLE TO MID-AMERICA ASSOCIATES. o PROOF OF WORKER S COMPENSATION COVERAGE o SIGNED DOCUMENTS TO INCLUDE: EMPLOYER APPLICATION, PLAN DOCUMENT, ADMINISTRATIVE SERVICES AGREEMENT, STOP LOSS APPLICATION, DISCLOSURE FORM AND COMPLETED COBRA ADMINISTRATION ELECTION FORM. Employee applications must be filled out completely, each question must be answered for EACH APPLICANT (SPOUSE AND CHILDREN). Details must be provided for ALL YES answers including details on medications, dates of service, physicians name, address, etc. Signature of both employee, spouse and dependent children 18 years and older must be included. Neither the Employer or Agent is authorized to complete or sign Enrollment Applications on behalf of applicants.

4 Fully Funded Employer Application 1. It is understood that no coverage is in effect until administrative fees, premiums and the level monthly claim fund costs have been received and notice of approval has been given by Mid-America Associates. 2. The undersigned Employer acknowledges and agrees that no one other than Mid-America Associates or a person designated in writing by Mid-America Associates may accept this application on behalf of Mid-America Associates. The undersigned employer agrees to comply with any applicable state laws, federal statutes or regulations regarding its operation. 3. The undersigned Employer acknowledges that only eligible full-time active employees working a minimum of 30 hours per week on average and included on regular payroll are eligible for coverage. 4. Administrative fees, premiums and the level monthly claims fund costs are payable monthly and due on the first of each month. The undersigned Employer understands and agrees to pay all monthly administrative fees, premiums and level monthly claims fund costs as of the effective date of coverage through the Plan Anniversary. Non-payment of administrative fees, premiums and level monthly claim fund costs does not discharge the undersigned from this obligation. The undersigned Employer understands that changes to coverage may be made on the Plan Anniversary only. The undersigned Employer also understands that rates may be modified at each Anniversary, or sooner if there is a significant change in participation and/or non-disclosure or intentional misrepresentation during the enrollment process by the Employer or Member. 5. The undersigned Employer understands the underwriting and participation requirements. In the event participation fails to meet minimum standards, or should the applicant submit false or incorrect information, the risk to premium ratio will be re-examined or coverage will be rescinded. Benefit coverage will become effective on the first of the month as requested and approved by Underwriting. Mid-America Associates reserves the right to rate coverage for the appropriate medical risk or decline coverage if all enrollment, participation or contribution requirements are not met. 6. The undersigned Employer understands that if administrative fees, premiums and level monthly claims fund costs are not received by the due date (first of each month), payments for claims incurred on or after the due date shall be discontinued until administrative fees, premiums and level monthly claims fund costs are paid in full. If administrative fees, premiums and level monthly claims fund costs are not received within 31 days after the due date, the Employer s coverage will terminate and no claims incurred on or after the premium due date will be paid. The Employer will be responsible for payment of prescription drug card benefits used during the Grace Period and applicable funding of claims incurred prior to coverage termination. 7. The undersigned Employer understands and agrees that the Third-Party Administrator, Mid-America Associates does not assume the Employers responsibilities for compliance with the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). 8. The undersigned Employer acknowledges that concurrent with participation in the Plan, Pre-Certification and Prior-Authorization is required for specific services under the Plan. The applicant agrees to participate and comply with the Pre-Certification and Prior- Authorizations Programs. Failure by any Member to obtain Pre-Certification and/or Prior-Authorization will result in a reduction or denial of benefits. The applicant understands that compliance with the provisions of the Pre-Certification and/or Prior-Authorization Programs does not constitute a confirmation of eligibility or assure the services billed are payable or eligible expenses. All terms, limitations and exclusions contained in the Plan will apply. 9. Deposit of one (1) month s administrative fees, premiums and level monthly claim fund costs in the amount of $, made payable to Mid-America Associates is enclosed with this application. It is understood that if this application is not approved, said deposit will be refunded. Do not cancel current coverage until after notice of approval has been received from Mid-America Associates. Applicant s Statement I hereby verify that the preceding information is complete and accurate. Employee applications have been completed, signed and dated by the individual applying for coverage. Any alterations to these applications that may have been made are initialed by the individual applying for coverage. I confirm that all eligible employees including those not actively at work will have completed either an application or waiver of coverage. I understand late applications received after the Plan effective date will not be accepted. I also understand the underwriting of individual applications has been predicated upon the answers to questions contained herein. Material misrepresentation of facts including intentional non-disclosure on the part of the Employer, Employee or dependent will result in rescission of coverage or retroactive adjustments to the administrative fees, premiums and level claims fund costs. Applicant s Signature Month Day Year Agent s Statement I hereby confirm that applications have been completed, signed and dated by the individual applying for coverage. Any alterations to these applications that may have been made are initialed by the individual applying for coverage. I understand that the underwriting of the individual applications taken in this case has been predicated upon the answers to the questions in said applications and where there has been a material misrepresentation of facts including intentional non-disclosure on the part of the Employer, Employee or Dependent, rescission of coverage or retroactive adjustments to administrative fees, premiums and level claim fund costs will occur. As the undersigned Agent, I have reviewed the Employer and Employee Applications and have no knowledge of material misrepresentation or non-disclosure of fact. I have reviewed the requested coverage for accuracy and it complies with the coverage the employer desires. Writing Agent s Signature Month Day Year General Agent s Signature Month Day Year Administered by: Mid-America Associates, Inc. 560 Kirts, Suite 125 Troy, MI (800) Underwritten by: National Guardian Life Insurance Company 2 E. Gilman Madison, WI Fraud Warning: Any person who knowingly, and with intent to injure, defraud, or deceive any insurance company, files a statement containing any false, incomplete, or misleading information is guilty of fraud.

5 NATIONAL GUARDIAN LIFE INSURANCE COMPANY PO Box 1191, 2 East Gilman Street, Madison, WI [ ] APPLICATION FOR STOP LOSS INSURANCE Applicant (Plan Sponsor) (Full Legal ) Address: Nature of Business: Requested Effective : Initial Premium Deposit: Tax I.D. # (This effective date is subject to National Guardian Life Insurance Company s approval.) Indicate Affiliates or Subsidiaries to be included under the insurance, if any. Location Relationship Business # of Employees Select Covered Unit Category and Number of Covered Units: Employee Only Employee + Spouse Employee + One Employee + Child(ren) Employee + Family Employee Composite Aggregate Stop Loss Coverage Covered Benefits: Monthly Aggregate Deductible Factors: Employee Employee Employee Employee Employee Employee Only + One + Spouse + Child(ren) + Family Composite Medical $ $ $ $ $ $ ] Total $ $ $ $ $ $ Minimum Aggregate Deductible: The greater of $Total monthly Aggregate Deductible Factors multiplied by enrollment (varies dependent on initial quote provided and actual enrollment numbers) or 50 % of monthly aggregate factors times the first's month enrollment times the Monthly Aggregate Deductible Factors times the number of months in the Policy Year. Claim Basis: xx Incurred and Paid 12/24 Incurred and Paid [12/15] Other Losses incurred prior to Effective will be limited to $0.00 Select Covered Unit Category and Number of Covered Units [ Single Family] [ Employee Dependent(s)] [ Spouse Child(ren)] [ Spouse and Child(ren)] [ Dental] [ Vision] [ Prescription Drug Expenses] [ Other] Deductible Amount: $ [Individual Lifetime Maximum: $ ] Specific Not Stop Loss Coverage Aggregate Percent Reimbursable:100% Monthly Rate per Employee: $ N/A OR % of Monthly Aggregate Deductible Factors: 100% Annualized Premium: $ 0.00 payable in advance. Monthly Aggregate Accommodation: XX Yes No If yes, monthly rate per covered employee $ Included Annual Maximum Liability $N/A ] Claim Basis: Incurred and Paid [(12/12)] Paid Other Losses incurred prior to Effective will be limited to $ Applicable Specific Percent Reimbursable % Monthly Rates: Per Single $ Per Family $ Per Employee $ Per Dependent $ Per Spouse $ Per Child $ Per Spouse & Child Third Party Administrator (if applicable):mid-america Associates, Inc. 560 Kirts Blvd Suite 125 Troy, MI Utilization Review Provider (if applicable):american Health Holdings Large Claim Provider (if applicable): American Health Holdings NGLAPP1 2/06

6 OUTSTANDING UNDERWRITING ITEMS The Monthly Aggregate Deductible Factors and/or specific deductible amount and rate(s) stated herein are based on information submitted by the Applicant to National Guardian Life Insurance Company (NGL) for underwriting the coverage. The amounts and rates quoted are tentative and subject to receipt by NGL of all of the items previously communicated to the Applicant by NGL or its agents as a part of the NGL quote for Stop Loss. No Stop Loss Coverage will be in effect until NGL receives all requested Underwriting Items and has approved the Application. PARTY - AGREEMENTS AGREEMENTS: The Applicant hereby applies for Stop Loss coverage and: 1. Represents that the answers included in this Application have been reviewed by the applicant and are true and complete to the best of the Applicant s knowledge and belief; 2. Understands and agrees that insurance applied for shall not become effective until the application for insurance is approved by NGL at its Home Office; 3. Agrees that if the insurance applied for is approved by NGL, the Applicant will pay all premium due after the effective date of insurance, including any premium which may accumulate between the effective date of the insurance and the date the policy is issued; 4. Acknowledges that this Application is not an offer by NGL of Stop Loss Insurance. No Stop Loss Coverage will be in place until NGL has received the initial premium and has issued the Stop Loss Insurance Policy. INSURANCE FRAUD WARNING The Applicant has read the Fraud notice (on the next page) applicable to the Applicant s situs state. APPLICANT: (Full Legal of Applicant) By: Title: : AGENT: As the Agent of record on this case, I personally witnessed the applicant complete and sign this application. I also certify that the applicant has read or had read to him, the completed application and understands that any false statement or misrepresentation may result in loss of coverage under this policy. Agent Signature: Agent Printed : Agent Number: In Florida only, Florida ID#: NGLAPP1 2/06

7 FRAUD WARNING NOTICES: Please review the notice that applies to your state. For residents of: AL, AK, CT, DE, HI, ID, IL, IN, IA, MA, MD, MI, MN, MS, MT, NV, NC, ND, RI, SC, SD, UT, WV, WI, WY: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud. For residents of: GA, MO, NE, TX, VT: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information may be guilty of insurance fraud. For residents of Arkansas/Louisiana/ New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. For residents of Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. For residents of California: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. For residents of Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, and denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a certificate holder or claimant for the purpose of defrauding or attempting to defraud the policy or certificate holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department regulatory agencies. For residents of District of Columbia: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. For residents of Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. For residents of Kansas: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information may be guilty of committing a fraudulent insurance act. For residents of Kentucky /Ohio: I understand that any person who, with intent to defraud, or knowing that he or she is facilitating a fraud against an insurer, submits an application containing a false or deceptive statement is guilty of insurance fraud. For residents of Maine/Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefit. For residents of New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. For residents of Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. For residents of Tennessee: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. For residents of Washington: Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under state law. NGLAPP1 2/06

8 SEND APPLICATION, DEPOSIT PREMIUM AND SUMMARY PLAN DOCUMENT/BENEFIT BOOKLET TO: UNDERWRITING MID AMERICA ASSOCIATES, INC. 560 KIRTS BLVD. SUITE 125 TROY, MI FAX: (248) PHONE: NGLAPP1 2/06

9 National Guardian Life Insurance Company ( The Company ) EMPLOYER DISCLOSURE STATEMENT Employer : Proposed Effective : Should you require additional space to complete this form, please use the reverse side of this form or attach a separate sheet of paper. If a field does not apply please indicate with N/A. 1. List those employees who are currently not actively-at-work and/or will not be actively-at work on the coverage date. Employee (or same) of Birth Last Worked Diagnosis Prognosis Claims Paid Claims Pending 2. List all covered individuals who are currently hospital confined, include active employees, COBRA and COBRA eligible individuals, IRS 1099 employees, covered retirees, and all their dependents who are eligible for coverage. Employee (or same) of Birth Disabled Diagnosis Prognosis Claims Paid Claims Pending 3. List all COBRA and COBRA eligible individuals. Employee (or same) of Birth Disabled Diagnosis Prognosis Claims Paid Claims Pending 4. List all IRS 1099 employees. Employee (or same) of Birth Disabled Diagnosis Prognosis Claims Paid Claims Pending 5. List all covered retirees. Employee (or same) of Birth Disabled Diagnosis Prognosis Claims Paid Claims Pending NSL-EDS1 2/06

10 [6.] List all covered persons who have incurred medical or prescription drug expenses in excess of 50% of the specific deductible (paid or pending) in the last 12 months. Employee (or same) of Birth Disabled Diagnosis Prognosis Claims Paid N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Claims Pending [7.] Other than those individuals listed above, please list any other covered person a) for whom medical or prescription drug expenses are expected to reach or exceed 50% of the specific deductible and/or b) who is known to have any of the following conditions: AIDS, ARC, or HIV Positive as diagnosed by a member of the medical profession, or cancer, leukemia, cardiovascular disease, any disorder of a major organ system, burns or trauma, any form of paralysis, premature infancy, and/or c) who has a major surgical operation anticipated or planned, or is a potential organ transplant candidate. (Note: HIV test results from anonymous counseling and testing sites or from home test kits do not have to be disclosed.) Employee (or same) of Birth Disabled Diagnosis Prognosis Claims Paid Claims Pending We agree the proposed coverage is subject to the terms and provision of the Company s contract. We have listed above all individuals identified as requested, as of the signature date. The amount of claim payments on these individuals along with their current status have been indicated. After diligent review, we represent that the above information is complete and accurate to the best of our knowledge and belief. We acknowledge that the Company retains the right to re-underwrite any individual whose actual claims (paid or pending) are greater than the amounts reported (above or previously) to the Company by more than $10,000 as of the signature date below. We further acknowledge, understand and agree that this information may be used by the Company in evaluating and determining the acceptability of the Employer s risk and that receipt of this form can not be construed in any manner as to bind coverage. In addition, we understand that no coverage shall be provided for above listed persons unless specifically agreed to in writing by the Company. By Officer-Employer ( and Title) Agent (As agent of Employer) : : NSL-EDS1 2/06

11 MID-AMERICA ASSOCIATES, INC. FULLY-FUNDED PLAN - SUMMARY SIGNATURE PAGES ADMINISTRATIVE SERVICES AGREEMENT This Administrative Services Agreement and accompanying exhibits and appendices which are attached hereto and incorporated herein (collectively referred to as the Agreement ) is made and entered into this day of, 20 (the Effective ), by and between, a [corporation] duly organized and existing under the laws of the State of with its principal place of business at (hereinafter referred to as the Plan Sponsor ) and Mid-America Associates, Inc (corporations duly organized and existing under the laws of the State of Michigan with its principal place of business at Troy, Michigan (hereinafter referred to as the "Administrator Authority. Each party represents and warrants to the other that the signatory identified beneath its name below has authority to execute this Agreement on its behalf. The parties, intending to be legally bound, have executed and delivered this Agreement as of the date set forth. IN WITNESS WHEREOF, the parties confirm delivery and acceptance of this Agreement by the Plan; the parties have caused this Agreement to be executed on their behalf by their duly authorized representatives signatures, effective the day of _, 20 The parties acknowledge the signatures represented on the Summary Signature Pages, will for all purposes, be considered as full execution and acceptance of this "Agreement" in its entirety. ADMINISTRATOR: Mid-America Associates, Inc Authorized Signature of Administrator Printed of Authorized Administrator Title Plan Approved PLAN SPONSOR Signature of Authorized Plan Sponsor (Employer) Printed Title FF LULAC 1/2016 FF ASA/BAA MAA 1/2016 Signature Pages ASA/BAA Signature Pages

12 MID-AMERICA ASSOCIATES, INC. FULLY-FUNDED PLAN - SUMMARY SIGNATURE PAGES APPENDIX A DISCLOSURE FORM Agent (Full ): Administrator: Mid-America Associates, Inc. In conjunction with the sale of the group health plan you have selected to purchase, this arrangement does not limit your Agent and/or Administrator from marketing for other insurance companies or organizations. The Agent and/or Administrator may be entitled to commissions and/or marketing allowances on such contracts, expressed as a percentage of gross annual premium and/or a flat dollar amount, as follows: AGENT ADMINISTRATOR % of Aggregate Premium % of the Aggregate Premium % of Administration Fee % of Administration Fee Other 25% Subrogation Recoveries Full PBM Rebates/Performance Guarantees In addition to commissions, Agent and/or Administrator may receive additional compensation in the form of cash bonus and/or certain travel bonuses awarded by the Administrator or other ancillary service providers. The bonus is developed and paid by the Administrator or other ancillary service providers based on several aspects of Agent s/administrator s entire block of business with the carrier or other ancillary service providers. The undersigned acknowledges receipt of the various proposals and the statement prior to any purchase and approves this transaction on behalf of the Plan without receiving, either directly or indirectly, any personal compensation in connection with the purchase of administration services or policies under the Plan. Signature of Agent of Plan Sponsor (Employer Group ) FFMAA 1/2016 ASA/BAA Signature Pages

13 MID-AMERICA ASSOCIATES, INC. FULLY-FUNDED PLAN - SUMMARY SIGNATURE PAGES COBRA ADMINISTRATION ELECTION Exhibit X COMPLETE FOR NEW BUSINESS ONLY If you employed 20 or more full and part-time employees for at least 50% of the prior calendar year, you may be required to comply with COBRA (Public Law , Title X - Continuation Coverage). The Administrator will provide this service for the Plan, if elected. Complete the Plan election below and submit with the Employer Plan Application. Refer to the Plan Document for Employer COBRA compliance responsibilities. Indicate below if the Employer is subject to or exempt from the regulations mandated under the Consolidated Omnibus Budget Reconciliation Act of 1985 known as COBRA: Complete for new business only do not complete for renewal business, Employer is exempt; having less than 20 full and part-time employees for at least 50% of the previous calendar year. Skip to bottom. Sign, date and return form. Employer is subject to COBRA; having 20 or more full and part-time employees for at least 50% of the previous calendar year. Employer declines COBRA administration services. Services performed: Internally by the Employer or outsourced to another administrator. Employer elects COBRA administration services for the calendar year. Employer is responsible to notify the Administrator of all terminations and qualifying events in a timely manner (within 14 days of occurrence). Consequences of untimely notice to the Administrator will be the Employer's responsibility. of Responder Title Responder's Signature FF MAA 1/2016 ASA/BAA Signature Pages

14 MID-AMERICA ASSOCIATES, INC. FULLY-FUNDED PLAN - SUMMARY SIGNATURE PAGES PLAN DOCUMENT SIGNATURE PAGE - Exhibit XI The Company assures its covered members that during the continuance of the Plan all benefits hereinafter described shall be paid, to or on behalf of them, in the event they become eligible for benefits. The Plan is subject to all terms, provisions and conditions recited on the following pages hereof. The Plan is not in lieu of, and does not affect any requirements for coverage by Workers' Compensation Insurance. WITNESSETH WHEREAS, effective, (hereinafter called "Plan Effective "), the Company heretofore established a Plan for payment of certain expenses for the benefit of its eligible members known as the (Employer ) Fully-Funded Group Employee Benefit Plan; (hereinafter referred to as the "Plan"). AND WHEREAS, under the terms of the Plan, the Plan Administrator acknowledges that amendments to the Plan will not be recognized or enforced without prior written approval from the Administrator. AND NOW, THEREFORE, it is understood and agreed that: (1) the undersigned has read this Plan in its entirety, has consulted legal and tax counsel to the extent considered necessary, acknowledges that he finds the Plan suitable for his purposes, and further acknowledges that he understands that the Plan has not been the subject of a favorable determination letter from the Internal Revenue Service or any other governmental agencies having jurisdiction over the Plan pursuant to ERISA, and accepts full responsibility for participation hereunder. PLAN SPONSOR Legal of Employer Authorized Plan Sponsor Signature Title FF MAA 1/2016 ASA/BAA Signature Pages Group Number

15 NOTES

16 MID-AMERICA Corporate Office: 560 Kirts, Suite 125 Troy, MI (800) (248) Mailing Address: P.O. Box 5047 Troy, MI MID-AMERICA ASSOCIATES Mid-America is a Third-Party Administrator servicing Small Businesses for over 50 years. Corporate Office: 2 E. Gilman Madison, WI Stop Loss Insurance coverage provided by National Guardian Life Insurance Company. National Guardian Life Insurance Company is not affiliated with The Guardian Life Insurance Company of America, a/k/a The Guardian or Guardian Life. MAFF MAA Rev. 7/1/2016