Premium Amount HEALTH PLAN QB Only Enrolled $ Total Premium for Next Payment Due on 1/1/2018: $000.00

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1 115 Continuum Drive Liverpool, NY << ADDRESS >> << CITY >>, << STATE >> << ZIP >> 12/12/2017 Dear JOHN PRODUCTUCTION: Effective January 1, 2018 Lifetime Benefit Solutions will be your new COBRA premium billing administrator. Included with this letter are monthly coupons that detail your future premium payments. We provide you with many convenient ways to make your monthly premium payments including: Pay by check via mail Set up monthly recurring payments from your bank account (ACH) via our secure web portal One time payments via our secure web portal ($20 convenience fee applies) One time credit card payments via our toll free customer service number at no charge Also included with this letter is information about the Lifetime Benefit Solutions Member Portal. The Portal provides you with the ability to monitor and maintain your continued coverage. You must pay your full premium payment by the end of your Premium Payment Grace Period in order to remain enrolled on the COBRA continuation plan(s). Your next scheduled payment, as well as any future COBRA premium payments, are due on the first of each month thereafter, and should be mailed on or before the due date for that month s coverage. You will have a grace period for each monthly premium payment which is listed on the second page of this letter. Failure to pay any regularly scheduled COBRA premiums by the end of the premium month's grace period will terminate your participation in the COBRA group health continuation plan(s). To ensure proper posting of your premium payment, it is required that you return the coupon with your payment if paying by mail. Your eligible benefits are fully explained in the "Summary Plan Description". This was given to all employees when they first became eligible for employee benefits. If you need a copy of the "Summary Plan Description", please notify Human Resources Department or you may contact the customer service department of your insurance carrier. Premium Information for Next Payment Due on 1/1/2018: Plan Name Coverage Level Status Premium Amount HEALTH PLAN QB Only Enrolled $ Total Premium for Next Payment Due on 1/1/2018: $ Plan Name First Day of COBRA Last Day of COBRA # Months of COBRA Grace Period Days HEALTH PLAN 1/1/2017 6/30/ Page 1 of 5

2 Your projected COBRA premiums for up to the next 12 months, if applicable, inclusive of any employer subsidy or premium assistance under the American Recovery and Reinvestment Act of 2009, if any, are listed below. These premiums are based on current information from and may change if plan premiums or your coverage election options change. Projected Plan Premiums Premium Due Total Amount Owed 01/01/2018 $ /01/2018 $ /01/2018 $ /01/2018 $ /01/2018 $ /01/2018 $ Premium payments via check should be remitted directly to the address below and made payable to Lifetime Benefit Solutions. Payment must be in the form of a check or money order. DO NOT send cash. Lifetime Benefit Solutions PO BOX 2979 Election form and all other correspondence should be sent to Lifetime Benefit Solutions PO BOX 332 Liverpool, NY SCHEDULED ACH PREMIUM PAYMENT OPTION Did you know you can set up scheduled ACH deductions from your bank account for your monthly payments? ACH is a safe, fast and secure way to ensure your monthly payment is made on time, every time. To sign up, login to your Member Portal and enter your banking information. Also, you may contact our offices and we will send you an ACH form and help with any questions or comments. If you have any questions regarding your coverage continuation, please contact our Customer Service Department at (877) during normal business hours or us at LBSMember@lifetimebenefitsolutions.com. Sincerely, Page 2 of 5

3 New Member Login Notice An integral part of our service is our Member Portal. This secure website provides tools and information to manage your continuation under the <<NAME>> group health plans. Examples of information and tools you'll find on the Member Portal include: 1. Payment Information (last received and next due) 2. Coverage Information (plans and critical dates) 3. Copies of all communications we've sent to you 4. Ability to make recurring or one-time payments Below is your unique registration identification number needed to become an authorized user of our website. Please visit and click on the NEW USER link and follow the registration process as described. Please note you will be asked to supply a second piece of identification which will be your social security number (SSN). In order to expedite the registration process, please make sure you have this information with you before beginning the new user registration process. << REGIS ID >> If you have any questions or comments, please contact us at (877) during business hours Page 3 of 5

4 Due : 1/1/2018 I hereby certify that any qualified beneficiaries, including myself, remain eligible for participation in COBRA continuation plan. PY Due : 2/1/2018 I hereby certify that any qualified beneficiaries, including myself, remain eligible for participation in COBRA continuation plan. PY Due : 3/1/2018 I hereby certify that any qualified beneficiaries, including myself, remain eligible for participation in COBRA continuation plan. PY Page 4 of 5

5 Due : 4/1/2018 I hereby certify that any qualified beneficiaries, including myself, remain eligible for participation in COBRA continuation plan. PY Due : 5/1/2018 I hereby certify that any qualified beneficiaries, including myself, remain eligible for participation in COBRA continuation plan. PY Due : 6/1/2018 I hereby certify that any qualified beneficiaries, including myself, remain eligible for participation in COBRA continuation plan. PY Page 5 of 5