Step 1: Read and complete this form.

Company Name _______________________________________

Paychex Health and Benefits Services Office/Client Number __________________________________
Agreement
Federal ID Number ___ ___ ___ ___ ___ ___ ___ ___ ___

This Paychex Health and Benefits Services Agreement (“Agreement”) is entered into between Paychex, Inc., (“Paychex”), located in, Rochester, New York and
the Company identified above (“Client”). This Agreement will continue until terminated in accordance with the provisions contained in this Agreement.

1. Services. Client contracts with Paychex to provide the services initialed below (“Services”). Each of the Services are described in the Product Terms and
Conditions section of this Agreement. Paychex will not commence any of the Services until Paychex receives all documents necessary to begin each of the
Services and notifies Client of the date Paychex will commence each of the Services (“Service Effective Date”). Client acknowledges that each of the
Services may have separate Service Effective Dates. Until the Service Effective Date, Client will provide for itself the Services requested of
Paychex. Paychex assumes no responsibility for services prior to the Service Effective Date.

Client agrees that Paychex is not rendering legal, tax, accounting, or investment advice in connection with the Services, nor is Paychex a
fiduciary of Client or the employer or joint employer of Client’s employees. Paychex will not be responsible for Client’s compliance with, nor will
Paychex provide legal or other financial advice to Client, with respect to federal, state, or local statutes, regulations, or ordinances, including, but not
limited to, the Fair Labor Standards Act or any state equivalent. Client agrees to comply with any and all applicable federal, state, and local laws or
ordinances.

The extent and availability of the Services provided under this Agreement are contingent upon Client’s insurance carrier selection (“Insurance Carrier”) and
Paychex’ agreement to provide such Services. A change in Insurance Carrier may result in modification or termination of Services provided to Client.
Paychex assumes no responsibility for services offered and provided by Insurance Carrier.

Insurance Payment Service for Group Health Plan

(INITIALS)

Insurance Payment Service for Individual Voluntary Plan

(INITIALS)

Disability Benefits Administrative Service

(INITIALS)

COBRA Administration
(INITIALS)

Premium Only Plan (POP)

(INITIALS)

Paychex has no authority to bind a carrier, modify plans, or waive any plan provision(s). This condition shall remain in effect until otherwise
advised by either party in accordance with provisions contained in this Agreement and shall not terminate any rights or liabilities arising out of a
period prior to termination.

Client understands that this Agreement (Rev. 5/13) may be considered an application for credit and hereby authorizes Paychex to investigate the credit of the
Client and/or its principals, including vendor references, bank account status, and history (collectively “Client’s Credit”). Paychex’ performance of the Services
under this Agreement is subject to approval of Client’s Credit. Client warrants that it possesses full power and authority to enter into this Agreement, and has
read and agrees to the terms and conditions of this Agreement.

Authorized Officer’s Name __________________________________________________ Title _________________________________________

PRINT

Authorized Officer’s Signature _______________________________________________ Date _________________________________________

Sign Here!

1 of 5 Rev. 5/13
Step 3: Designate at least one checking account.
Company Name _______________________________________
Checking Account Designation Office/Client Number __________________________________
Federal ID Number ___ ___ ___ ___ ___ ___ ___ ___ ___

Designate the checking account that will be used by Paychex to perform the following Services (check one or more)
by entering the routing number and account number below or by submitting a voided check.

 COBRA/State Continuation Premium Refund  EFT Payment for Paychex Services

 EFT Premiums Due for Insurance Payment Service  EFT Payment for Aflac

Bank Name _____________________________________________________________________________________

Routing Number _________________________ Account Number _________________________________________

MUST INCLUDE ALL 9-DIGITS MUST INCLUDE SPACES, DASHES, AND ZEROS

_________
INITIALS
I have verified that the routing and account numbers above are correct. Paychex shall use this information
to perform Services pursuant to the Service Agreement between the parties.

Step 4: Complete only if client is a live check draft (LCD) client for Insurance Payment Service and/or
Disability Benefits Administration Service.

Check Signing
Check Signing
Using a blue or black ink pen, sign within each bracket, and print your name below.

Single Signature Double Signatures

Use when one signature is required. Use when two signatures are required.
To ensure signature quality, stay within the brackets. To ensure signature quality, stay within the brackets.

PERSON 1

PERSON 2

PERSON 1

Print Name PERSON 2

____________________________________

Print Names

_______________________________________________

______________________________________________
Paychex Use Only
Font Name ___________ Effective Date ____________
Step 6: Read and complete this form when signing up for a Premium Only Plan (POP).

Organization Resolution Office/Client Number ______________________________

Adopting Paychex Employee Benefit Plan Federal ID Number ___ ___ ___ ___ ___ ___ ___ ___ ___

By action of the [Board of Directors] [Partnership/Membership] of ___________________________________ , a

(COMPANY NAME)

______________________ , taken on ___________ , the following resolutions were duly adopted.

(ORGANIZATION TYPE) (DATE)

WHEREAS, the [Board of Directors] [Partnership/Membership] of this organization has considered the salient
features of the following employee benefit plan:

 Premium Only Plan

which, when executed and carried out, will provide benefits to its employees and their beneficiaries; and

WHEREAS, it is believed that the adoption of the above-designated Plan will encourage continuous
employment and employee loyalty, in the mutual interest of the employees and the organization; and

THEREFORE, IT IS RESOLVED, that the [Board of Directors] [Partners/Members] of this organization

hereby adopt(s) the Plan designated above and do(es) hereby authorize the [proper officers] [General
Partner/Member] to execute an Adoption Agreement setting forth the terms and conditions of the selected
Plan; and it is

FURTHER RESOLVED, that Paychex is hereby appointed as Plan Service Provider to serve for such term(s)
and to have such powers and duties as set forth in the Plan and the applicable administrative service
agreement(s); and it is

FURTHER RESOLVED, that the Plan shall be effective for the Plan Year ending 20____ ; and it is
(YEAR)

FURTHER RESOLVED, that for the Plan adopted pursuant to this Resolution, that ____________________
(ADOPTING EMPLOYER or DESIGNATED INDIVIDUAL)

be and hereby is designated as Plan Administrator, and ___________________________ be and hereby is

(DESIGNATED INDIVIDUAL)

designated as Trustee.

IN WITNESS WHEREOF, I have executed this Resolution this date of _____________

(MONTH/DAY/YEAR)

_____________________________ _____________________________ ________________________________

(AUTHORIZED SIGNATURE) (PRINTED NAME) (PRINTED TITLE)

Sign Here!
Step 7: Complete this form with your Paychex sales representative.
Company Name __________________________________
Payment Information Office/Client Number ________________________________
Federal ID Number ___ ___ ___ ___ ___ ___ ___ ___ ___

Insurance Payment Service COBRA

Administrative (monthly) Administrative (monthly)
Charges are based on the number of participating employees. $ _______________
$ _______________ Monthly fee for first 20 participating employees
$ ___________ Per Active/Pending Participant
$ _______________ Each additional participating employee from 21-100

$ _______________ Each additional participating employee from 101- Premium Only Plan (POP)
500 Administrative (monthly)
40
$ _______________
$ _______________ Each additional participating employee from 501+

Prices subject to change with written notification. Please initial here to confirm your acceptance of the fees and payment option specified on this page and the payment terms contained in
the Paychex Health and Benefits Services Agreement.
INITIALS

.........................................................................................................................................................................................................................................................................................

Paychex Use Only

H&B Sales Representative Eric Coffaro Representative Number S8 40

Referring Representative Representative Number

COBRA Sales Representative Representative Number

Referring Representative Representative Number

POP Sales Representative Representative Number

Referring Representative Representative Number