PAYROLL DEDUCTION AUTHORIZATION, CHANGE & WAIVER

PAYROLL DEDUCTION AUTHORIZATION, CHANGE & WAIVER Employer Employee Work Location Agent DEDUCTION INFORMATION (Name and Number) Franchise # SSN Payroll # Enroller NEW POLICIES (Name and Number) Check One: Payroll Frequency: New (Initial Deduction) Increasing Prior Deduction Decreasing Prior Deduction Weekly (52 times per year) Bi-weekly (26 times per year) Semi-monthly (24 times per year) Monthly (12 times per year) Monthly (10 times per year) Other ( times per year) M M D D Y Y First Deduction Date* M M D D Y Y Issue Date* *Number of Deductions Required Before Policy Issue Date: Weekly........................................... 5 Bi-weekly.......................................... 3 Semi-monthly..................................... 2 Monthly.......................................... 1 Insured Name Face Amount or Product Existing Deduction Per Pay Period New Deduction Per Pay Period Total Deduction Per Pay Period Employee $ $ $ $ Spouse $ $ $ $ Child 1 $ $ $ $ 2 $ $ $ $ 3 $ $ $ $ Total Deduction per Pay Period $ DEDUCTION AUTHORIZATION I hereby authorize my employer to deduct from my pay each period the amount shown above as consideration for contract(s) issued by the various MHA Benefit Plan companies during the continuance of my employment by this employer or until this authorization is revoked by written notice to said employer. Date Signed Signature of Employee WAIVER OF PARTICIPATION My signature below certifies that I have been made aware of the features and benefits of the MHA Benefits Plan offered to me as an optional benefit through my employer, and I have decided not to participate at this time. I understand that my next opportunity to participate may not be until the end of one year. Date Signed Signature of Employee MHA Benefits Plan 1967 North Lockwood Avenue Chicago, Illinois 60639 FORM 1201 R 11/20/04 WHITE EMPLOYER * YELLOW FTF * PINK AGENT / ENROLLER * GOLDENROD APPLICANT

1967 N. Lockwood Ave. Chicago, Il 60639 773-889-2307 * Fax: 773-889-3033 * Toll Free: 888-881-2307 Worksite Preliminary Case Approval Sheet 1. Employer name: Phone number: ( ) (Indicate name to appear on proposal) 2. Employer address: (Street Address) 3. Nature of business: 4. SIC Code: 5. Most hazardous occupation: 6. How long in existence: 7. Is there a Union: 8. Strike History: 9. Union contract expiration date: / / 10. Has the work force changed by more than 20% in the past 5 years? If yes, why: 11. Number of employees: Number of part-time employees: Total # of eligible employees: 12. Employment mix: % White collar % Light blue collar % Heavy blue collar 13. Is this a multi-location case: If yes, how many locations: Which states: 14. Billing contact name: Phone Number: ( ) 15. Billing address: Fax Number: ( ) (Street Address) (City) (State) (Zip) 16. How are employees paid: Weekly Bi-Weekly Semi-Monthly Monthly Annually 9thly 10thly 17. Will employer provide census data electronically on a disk? 18. Will this employer remit premium by magnetic tape? If yes, provide format. 19. Will this case require multiple billing locations: If yes, give details in special remarks. 20. Will the employer pay any part of plan(s) costs: If yes, how much of total premium will be employer paid: % 21. Will this be sold with an: ERISA Plan Pension Plan 125 Cafeteria Plan None of the preceding 22. How often are open enrollments held: Annually Semi-Annually Quarterly Continuous 23. Will an enrollment firm be used: If yes, which one: 24. Enrollment start date: / / 25. Planned effective date: / / 26. Date of first deduction: / / 27. End of enrollment date / / 28. Is this your first MHA Benefit case: 29. Are you appointed with MHA? 30. Have you applied for non-resident licensing: Not applicable to this case 31. Do you want an employer proposal to be generated? If yes, what programs: 32. Name of agent / broker: Agent #: (Indicate name to appear on proposal) Name of agent / broker: Agent # (Indicate name to appear on proposal) 33. Your agency address: (Street address) (City) (State) (Zip) 34. Has employer agreed to supervisor meetings? 35. Has employer agreed to one-on-one meeting for all eligible employees during work hours? If no, why not? 36. Is any other payroll deduction plan now in effect? If yes, will it be: Discontinued? Replaced? Continued side-by-side? Name other carrier(s): 37. Special remarks: *REMINDER A census with the employees hire date must be submitted with this form. (electronically preferred) _ Policy effective dates are based on information on this form and verification with the contact person at the participating company. HOME OFFICE USE ONLY Case approval date: Agent notified date: Form No. 1202 R 11/20/04

1967 N. Lockwood Ave Chicago, Il. 60639 773-889-2307 * Fax: 773-889-3033 Voluntary Product Billing Questionnaire YOUR NAME AND BILLING ADDRESS: (Use reverse side to list additional addresses) Name of Billing Contact: Phone Number: ( ) Fax Number: ( ) Do you require billing at more than one location? Yes No If yes, please indicate on the reverse side of this form. Do you require a monthly paper bill? Yes NO Would you be willing to send as a Statement of Deducted Monies on diskette? Yes No HOW ARE THE SALARY DEDUCTIONS TAKEN: Weekly Bi-Weekly Monthly Semi-Monthly Annual Deduction start date: / / When are company remittances done during the week? If more than one payroll mode, would you prefer to combine billings as one type of deduction? (ex: weekly deduction and monthly deductions, set up as all monthly) Yes No Our Standard Billing Set-up is: SSN, LAST NAME, FIRST NAME; Sorted by Last Name. Will you require another type of Billing Set-up? Yes No If yes, please check appropriate box below: Last Name, First Name; Sorted in Alpha Order SSN, Last Name, First Name; Sorted by SSN Disc Processing (Specifications are Attached) Last Name, First Name; Sorted by Employee Number Form No. 1203 R 11/20/04 Please complete and return this document to MHA Benefits Plan Make a photocopy for your records.

IF ADDITIONAL BILLING ADDRESSES ARE REQUIRED, PLEASE INDICATE BELOW. YOUR BILLING ADDRESS: 2. Attention: YOUR BILLING ADDRESS: 3. Attention: YOUR BILLING ADDRESS: 4. Attention: YOUR BILLING ADDRESS: 5. Attention: YOUR BILLING ADDRESS: 6. Attention:

EMPLOYER S ADMINISTRATIVE PROCEDURES FOR THE VOLUNTARY PAYROLL DEDUCTION PROGRAM This manual if furnished as a guide to assist you in handling almost any transaction which may come up in connection with your MHA Benefits Plan Account Program. If you don t find the answer you need, don t hesitate to call your agent or MHA Benefits Plan in Chicago, Il. at 773-889-2307, and Toll Free at 1-888-881-2307. On matters relating to billings or deductions, ask for the Group Billing Department. On any other matter, ask for Policy Service Department, Payroll Deduction Section. PREMIUM BILLINGS Each month, about seven to ten days prior to the premium due date (also called Common Due Date), you will receive two copies of a list billing for as well employees participating in your company s program. The billing will be arranged in the manner decided upon at the time the program was installed. The individual amount for each employee shown on the bill as Employee Total should equal the amount which has been withheld from that employee s pay by the due date shown on the billing. (If monthly billing is chosen sub-paragraphs 2 and 3 do not apply). 1. Verify each name and amount against the billing to check for accuracy. 2. If the amount withheld and the amount on the billing disagree, check the Payroll Deduction Authorization signed by the employee to be sure deductions were correct. If the amount deducted and the authorized amount agree with each other, but not with the billing, please contact us our your agent. 3. If the amount billed and the authorized amount agree, but the amount withheld does not, the adjustment should then be made to employee pay so the correct amount can be submitted with the billing. The withholding should be the amount deducted from the adjusted and the employee notified of the change. 4. If an employee fails to receive pay for any period(s), the missed deductions must be made up on the next payroll to prevent a lapse. If an employee terminates employment, retires, is laid off, goes on leave without pay, becomes disabled, or wants to discontinue or change deductions for any reason: 1. Write Terminated or other explanation beside the employee s name on the next billing statement, and draw a line through the dollar amount for that employee. 2. Write in the amount (if any) actually being remitted for the terminating employee. When you have completed all the previous steps, the total of all changed and unchanged amounts shown on the billing should match the total of your withholdings. Please sign in the space indicated to verify the bill is correct. One copy of the corrected billing, with attached Free Service requests, if any, should then be sent to MHA Benefits Plan along with your company s check for the correct amount due. (over)

IMPORTANT: It is essential to proper operation of the program that correct billings and premium payments be returned to MHA Benefits Plan no later than five working days following the due date. POLICY CHANGES Most of the policies issued to employees of your company will require some sort of change at one time or another in order to keep them up-to-date. Common changes include address change, beneficiary change, name change by marriage, and others. Also, service requests may arise from time to time. These may include withdrawals, and addition or deletion of a benefit rider. ADDRESS CHANGES It is essential for MHA Benefits to have the most up-to-date information for your company s employees at all times. Address changes may be reported to us on or with the billing statement, by calling Policy Service, Payroll Deduction Department, or on the Free Service cards. Terminating employees are entitled to continue their policies through a different mode of payment (monthly bank draft, semi-annual if the premium payment is $100 or more, or annual direct), so it is particularly important that we be able to contact them at once when they leave. OTHER CHANGES Requests for any other changes or services should begin with completion of a Free Service Request card. Each employee is furnished with one of these cards in his/her policy packet and a small supply is enclosed. The postage paid card is to be mailed to MHA Benefits Plan and will receive prompt attention. Urgent matters may be handled directly with your agent by telephone, or by calling MHA at 773-889-2307 or Toll Free at 1-888-881-2307. Ask for Policy Holder Service, Payroll Deduction Section. Normally, any type of policy change will be handled directly with the insured employee. DEATH CLAIMS In the event of death of one of your employee participants, please notify your MHA Agent or MHA at once. No further action on your part will normally be required. We will contact the beneficiary and provide all necessary forms and instructions to assist in filing the claim. Death claims can usually be processed in one or two days following receipt of the required forms, the policy, and a certified copy of the Death Certificate. A death claim on a policy which is less than two years old may take longer because it is subject to investigation. SUBSEQUENT ENROLLMENTS, CHANGES Enrollments into the MHA Benefits Plan Account are permitted any time, as per contract. All new entries into the program and all increases to existing coverage can also be done at any time. Form 1204 R 11/20/04

GUIDELINES AND PROCEDURES For the MHA Benefit Plan Programs Pre-Approval Policy Date Issue Ages Children s Signature All MHA Benefit Plan programs have to be pre-approved at the Home Office prior to enrolling the employees. The life/health policies will be dated at least 30 45 days after the first deduction date. Issue ages are for the most part 18 70 for employees, 18 70 for spouses, six months 21 for dependent children, and six months 16 for grandchildren, depending on the product and the company. When parents are applying for insurance on their children, the child must be at least six months old as of the policy date. If a child is 19 years old or older, he or she must sign the application, except in Pennsylvania, children 18 or older are required to sign the application. Signature Other The employee can always sign for the children and grandchildren 18 Than Employee and younger. Most states will allow the employee to sign the application for a spouse. The states that require signatures are Colorado, Indiana, Pennsylvania, South Carolina and Utah. Step Children Waiver Benefit If the employee is the step-parent to the proposed insured, the individual application will not need to be signed by the natural parent.. Available on issue ages 17 55 (most companies). Submitting Applications must be submitted to MHA Benefits Plan at least 10 Applications days prior to the first deduction date. Deductions per Period Mailing Policies When Issued Social Security Numbers Policy Verify prior to enrolling the case that the deductions will be based upon the pay period of the employee. If the company will deduct premiums differently than how the employee is paid, the application will need to be filled out accordingly. For example, the employees are paid bi-weekly, but the company will deduct the premiums only twice a month. On the applications, the deduction per pay period to be used would be semi-monthly and calculated on that assumption. Policies are mailed directly to the policy owner s home address as soon as they are issued. If an application is amended, the policy will be mailed to the agent / agency for delivery. The Social Security number is required for each insured. The Social Security number is the means by which MHA Benefits tracks and identifies the policies. (over)

Owner Replacement Compensation Important Disclosures: Protection of the Consumer The employee is the owner because he or she is signing the application. If the situation requires the signature of the insured. i.e., child over the age of 18, then the person signing the application can be the owner. If the applicant is replacing his or her existing coverage with a MHA company s product, fill out the necessary replacement forms and submit to the Home Office along with the name and address of the other carrier. Existing policy numbers are required, so give all pertinent information. (If the coverage being replaced is group term, replacement papers are not normally required. Form 1092, Compensation Agreement for MHA Benefits Plan, must be completed and signed by each agent involved along with the percentage to be paid to each agent. The agent who will service the case will sign on the top line as the servicing agent. This form must be left attached to the application. It is to be signed and dated by the employee and the agent. Form 1205 R 11/20/04

VOLUNTARY MHA BENEFITS PLAN ESCROW ACCOUNT AGREEMENT MHA Benefits Plan and Employer, agrees to provide for the Employer s eligible employees a Payroll Deduction Program for payment of premiums on MHA Benefit Plan Programs. The employer will deduct from the salary or wages of all participating employees the premiums on their and/or their family members policies or programs and will remit the amount so deducted to MHA Benefits Plan at its Home Office in Chicago, Illinois, on the Common Due Date(s), (as defined below). The employer will give prompt notice to, agent, or to the Home Office of the Company, of the name(s) and policy number(s) of any participant who leaves its employ, changes or withdraws a payroll deduction authorization, dies, or for whom payroll deductions will no longer be made for any reason. Eligible employees will be those who have been employed for the minimum time required for the payroll deduction program selected at enrollment date and (Other Requirements, if any) The Common Due Date for this program is the day of each month and the first Common Due Date for this Program will be. (Month, Day, Year) MHA Benefits will furnish to the Employer as part of each bill a detailed statement showing the individual and total amounts due and any current charges, according to its records at billing date. TERMINATION This agreement may be terminated at any time by the Employer or by MHA Benefits Plan upon furnishing 90 days written notice. If this agreement is terminated, the employer will be responsible only for the remittance to MHA of any full premiums deducted prior to the termination date. In the event deductions for any particular policy are to be discontinued on other than a Common Due Date, the amounts already withheld from pay, if any, are to be refunded to the employee, and MHA is to be notified as provided above. Executed this day of, 20 MHA Benefits Plan, Chicago, Il. By: Geri Ann Cangelosi Employer By Form No. 1206 R 11/20/04 (Signature / Title

COMPENSATION AGREEMENT FOR PAYROLL DEDUCTION APPLICATIONS DATE: Name of Payroll Deduction Group: I (WE) the undersigned, hereby understand and agree that any compensation otherwise due me (us) on the above named group, shall be paid to the Designated Agent(s) on the basis of the percent of premium shown below. This Agreement is to be signed and executed by any and all designated agents. A. Print Agent Name Agent Signature Agent Number Percent of Premium Servicing Agent: (The servicing agent will receive all correspondence) Writing Agent: Writing Agent: Writing Agent: Writing Agent: Writing Agent: B. Enrollers will be used but are paid by the agent. Accepted by MHA Benefits Plan by: Title: Date: IMPORTANT NOTICE ALL AGENTS AND ENROLLERS MUST BE LICENSED IN THE STATE WHERE POLICIES ARE SOLD AND MUST BE APPOINTED BY MHA BENEFITS Form No. 1092 R 11/20/04