Benefit Plans Administrative Services BPAS 3/9/2020

ARTICLE IV. BENEFITS UNDER THE PLAN 4.1 Benefits. The Plan shall reimburse Eligible Expenses in accordance with Section 3.4 and this Article IV. 4.2 Health Care("HC") Account. The HC Account will be credited with the Employer Contribution. A Participant's HC Account will be decreased from time to time in the amount of payments made to the Participant for Eligible Expenses. 4.3 Claims for Reimbursement. A Participant may obtain reimbursement of Eligible Expenses by submitting a paper claim or through an electronic payment card as described below. (a) Paper Claims. A Participant may make a claim by completing a claim form and submitting such form to the Claims Administrator setting forth at least the following: (1) the amount,date and nature of the expense,including the identity of the individual who incurred the expense; (2) the name of the person or entity to which the expense was paid or is owed; (3) the Participant's statement that the expense has not been reimbursed and the Participant will not seek reimbursement for the expense; and (4) such other information as the Claims Administrator may require. Such claim form shall be accompanied by such bills, invoices, receipts, explanations of benefits ("EOB") issued by a health plan, or other statements from an independent third party as is necessary to establish that an Eligible Expense has been incurred and the amount of the expense. The Claims Administrator is entitled to rely on the information provided on the claim form in processing claims under this Plan. A claim must be submitted for payment within the time period indicated in the Adoption Agreement. Where circumstances beyond the Participant's control prevent submission within the described time frame, notice of a claim with an explanation of the circumstances may be accepted by the Claims Administrator as a timely filing. Claims shall be determined in accordance with Article VI. (b) Electronic Payment Card. A Participant may receive reimbursement of an Eligible Expense by use of an electronic payment card at the time the Eligible Expense is incurred. The use of the electronic payment card shall be subject following conditions: (1) The electronic payment card will be deactivated when a Participant's participation in the Plan terminates. (2) The balance of the electronic payment card shall be limited to 90% of the balance of the Participant's HC Account. (3) A Participant must certify in writing prior to issuance of the electronic payment card that: (i) the electronic payment card will be used only for Eligible Expenses that have not been reimbursed under any other plan covering similar benefits; and ©2017 Hitesman&Wold,P.A. 9 Funded Post-Employment HRA Basic Plan Document(Single Employer Non-ERSA)