Benefit Plans Administrative Services 12/26/2018

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 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). ❑ Upon completion of the account transfer described in Section 5.1. ® Other (Describe): based on CBA, MOU, Labor Contract or any other agreement for a Union or Non-Represented Participant. 3.6 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: The period of time following the end of Plan Year(Section 4.3 of BPD) or the termination of a Participant's participation in the Plan (Section 4.7 of BPD) during which the Participant may submit claims to the Plan for expenses incurred during the Plan Year or the Participant's participation (as the case may be). 4.4 Expenses must be incurred: ® After termination of the Participant's employment with Employer ❑ Additional events: 4.7 Post-death Access by Spouse & Dependents: ® As provided in the Basic Document. ❑ Other (Describe): Post-death Access by Designated Beneficiary: ® Allowed as provided in the Basic Document. ❑ Not allowed. 4.9 Forfeitures occur: ® As provided in the Basic Document. ❑ Other (Describe): ©Copyright 2017 Hitesman&Wold, P.A. Page 3 PRA Basic Plan Document Adoption Agreement(Single Employer Non-ERISA)