Benefit Plans Administrative Services 12/26/2018

3.4(b) Coverage option determined as follows: ❑ N/A Z 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 I Other (Describe): ARTICLE IV: BENEFITS UNDER THE PLAN 4.3(a) Claims Run-out Period: The period of time following the end of the Plan Year or the termination of a Participant's participation in the Plan during which the Participant may submit claims to the Plan for expenses incurred during the Plan Year or the Participant's participation. Claims eligible date is January 1, 2019. ©Copyright 2017 Hitesman&Wold, P.A. Page 3 HRA Basic Plan Document Adoption Agreement(Single Employer Non-ERISA)