Benefit Plan AdministrativeS ervices BPAS 4/28/2020

3.4(b) Coverage option determined as follows: ❑ N/A ® As provided in the Basic Plan Document(i.e., Full Scope Option unless affirmative election of another option) ❑ Participants enrolled in the high deductible health plan are automatically enrolled in the following option unless they affirmatively elect another option: ❑ Limited Scope Option. ❑ Suspended Account Option. 3.4(c) Reimbursement rules: ❑ N/A ® As provided in the Basic Plan Document ❑ Other: 3.5 Effective date of waiver upon termination of employment: ® Date the Participant's employment with the Employer terminates ® Last day of the month in which the Participant's employment with the Employer terminates ❑ Date on which the Participant's coverage under the applicable group medical plan terminates Expiration of opt out election: ® At the end of the Plan Year. ❑ N/A-Opt out election is permanent. ❑ Other(Describe): 3.6 Termination of Contributions: ® As provided in the Basic Plan Document(i.e., upon ceasing to be eligible, termination of employment, death, or termination of plan). ❑ Other(Describe): 3.7 Termination of Participation: ® As provided in the Basic Plan Document ❑ Other(Describe): ARTICLE IV: BENEFITS UNDER THE PLAN 4.3(a) Claims Run-out Period: In general,there is no deadline for filing claims. However, when (1)a Participant dies without a surviving Spouse or Dependent, (2)a deceased Participant's last surviving Spouse or Dependent dies,or(3) a Participant opts out of the Plan,all claims incurred prior to the date on which such person's participation ceases must be submitted to the Plan within 365 days following the date on which participation ceases. Forfeiture of the HC Account will not occur until such deadline has passed. 4.7(a) Post-termination Access: ❑ In lieu of COBRA continuation coverage (if applicable), the former Participant may ©Copyright 2017 Hitesman&Wold,P.A. Page 3 HRA Basic Plan Document Adoption Agreement(Single Employer Non-ERISA)