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1 <br /> EXHIBIT A <br /> Fee Schedule <br /> Employer shall pay SISCO the following ACAWORKS access fees as described below: <br /> A. Set Up Fee. The set up fee is due upon execution of this Agreement. <br /> B. PEPM Fee. Employer shall pay SISCO a set access fee calculated per employee, per <br /> month (hereinafter"PEPM"),the first installment of which is due and payable upon execution of this <br /> Agreement and then payable monthly, as invoiced,thereafter. Failure to pay any invoice when due will <br /> constitute a material breach of this Agreement. Moreover, any amount past due over thirty(30)days will <br /> accrue interest at 1.5%per month. <br /> Fee Schedule <br /> One Time Set Up Fee' $2,150.00 <br /> Monthly PEPM Fee2,3 $0.90 <br /> Annual IRS Electronic Filing Fee $520($100 per add'l EIN) <br /> Annual Paper Employee Statement Fee $1.30 per statement <br /> Annual Electronic Employee Statement Fee4 $0.95 per statement <br /> Possible One Time Additional Set Up fees1 <br /> Employer EINs $100 per add'l over one, if applicable <br /> User Login $50 per add'l over two, if requested <br /> Payroll engines $250 per add'l engine over one, if applicable <br /> Medical Insurance Plans $50 per add'l over one, if applicable <br /> Bargaining Units $50 per add'l over one, if applicable <br /> Employee Classification for Insurance Plans $50 per add'l over one, if applicable <br /> 1 One Time Set Up Fees may increase based upon multiple payroll engines,insurance plans,employee classifications and/or data file complexity. <br /> 2 Ongoing fees include all full-time,part-time,variable,and seasonal employees. <br /> 3 A change in employee population of+/-20%may result in the re-evaluation of monthly administration fees. <br /> 4 By offering electronic statements,the employer will be provided with an instructional notice to distribute to employees.Those employees must <br /> go to a secure website, make their election to receive their statement electronically,create en online account,and will then have the ability to <br /> view,print,and download their statement themselves.Electronic statements will not be distributed via e-mail.Employees not using the electronic <br /> statement option will receive a paper statement subject to the paper employee statement standard fee. <br /> CITY OF EVERETT SELF INSURED SERVICES COMPANY <br /> Signature: Signature: <br /> (Authorized Officer) (Authorized Officer) <br /> Printed Name: Printed Name: <br /> Title: Title: <br /> Date: Date: <br /> Benefit Coordinators Corporation•www.benXcel.com <br /> Two Robinson Plaza,Suite 200,Pittsburgh,PA 15205•t 412.276.1111•f412.276.6650 <br /> 10805 Rancho Bernardo Road,Suite 130,San Diego,CA 92127 <br /> 6 <br />