Alliant Employees Benefits 8/8/2016

STATE RETIREMENT SYSTEMS FORM ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT ALL SERVICE PROVIDERS MUST COMPLETE AND SIGN THIS FORM 1. Does Service Provider have twenty-five(25)or more employees? ® Yes ❑ No IF YES: SKIP QUESTION 2, SKIP QUESTION 3,AND SIGN BELOW. IF NO: ANSWER QUESTIONS 2 AND 3. 2. If a Service Provider employee will perform Work under this Professional Services Agreement, did that employee retire under the Public Employers' Retirement System(PERS), School Employees' Retirement System(SERS), or Teachers' Retirement System(TRS)? ❑ Yes ❑ No 3. Answer the appropriate question below for Service Provider's business organization: Sole Proprietor. Did Service Provider retire under the Public Employers' Retirement System (PERS), School Employees' Retirement System(SERS), or Teachers' Retirement System (TRS)? ❑ Yes ❑ No Partnership. If a partner will perform Work under this Professional Services Agreement,did that partner retire under the Public Employers' Retirement System(PERS), School Employees' Retirement System(SERS), or Teachers' Retirement System(TRS)? ❑ Yes ❑ No Limited Liability Company. If a member will perform Work under this Professional Services Agreement, did that member retire under the Public Employers' Retirement System(PERS), School Employees' Retirement System(SERS), or Teachers' Retirement System(TRS)? ❑ Yes ❑ No Corporation. If a shareholder will perform Work under this Professional Services Agreement, did that shareholder retire under the Public Employers' Retirement System(PERS), School Employees' Retirement System(SERS), or Teachers'Retirement System(TRS)? ❑ Yes ❑ No Service Provider Name: Alliant Insurance Services Service Provider Phone Number: 206-204-9100 Signature - e: )t (a v.k J TitIe: S/ M4)4411kX1 y D1P-c_LTog_ (Retirement Form Approved by City Attorney's Office January 1,2010) Page 10 2016 Alliant Professional Services Agreement