Okaloosa County BOCC — August 16, 2016 — Enrollment Summary with Benefit Changes 10-1-2016 Okaloosa County BCC

ENROLLMENT SUMMARY For Groups with 51+ Eligible Employees Medicare Secondary Payor Compliance Multiple Employer Plan: a plan sponsored by more than one employer. Multi-employer plan: a plan jointly sponsored by employers and unions. If you are a single employer plan: ✔ Yes No Our Company employed 20 or more employees** each working day in 20 or more calendar weeks during the current or preceding calendar year. If you are a single employer, multiple employer, or multi-employer plan: ✔ Yes No Our Company employed 100 or more employees** on 50 percent or more of the business days during the preceding calendar year. If you are a multiple employer or a multi-employer plan: All employers in our Group Health Plan (GHP) employed 20 or more employees** for 20 or more weeks in either the current or Yes No proceding calendar year. Yes No At least one of the employers in our GHP employed 20 or more employees** for 20 or more weeks in either the current or preceding calendar year. Yes No All employers in our GHP employed fewer than 20 employees** for 20 or more weeks in either the current or preceding calendar year. **"Employees" includes all full and/or part time employees Common Ownership/Controlled Group Compliance Yes ✔ No Our Company is part of a common ownership or Controlled Group as defined by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") states that all persons treated as a single employer under subsection (b), (c), (m), or (o) of section 414 of the Internal Revenue Code of 1986 shall be treated as one employer. General Information Group Name Okaloosa Co Bd of Co Commissioners 59-6000765 Tax ID # Group Number 41954 Group Sales Rep/Agent Dave Sanna/Glenn Little Effective Date Oct 1, 2016 Employer Contribution Toward Employees Premium (50% recommended for groups with 51+ employees) 100 What was the average total number of all employees (full-time, part-time, and seasonal) in the previous calendar year? 1,076 II. Recap of Employee Participation Participation must be collected in certain scenarios. Please use the drop down and select the option that most fits your company. Renewal w/76 or more Enrolled with Benefit Changes Provide information regarding the questions listed below in the right hand column. Some cells are auto-calculated and can not be typed within. 1. How many TOTAL EMPLOYEES ON PAYROLL do you have? 824 2. How many TOTAL COBRA CONTINUANTS are currently enrolled in your Group Health Plan (GHP)? 3 3. The form will calculate the TOTAL INELIGIBLE EMPLOYEES according to answers in 3A through 3C below. 118 A. How many Total Part Time and Seasonal Employee(s) do you have currently have? 93 B. How many Total New Employees (in Waiting Period) do you currently have? 25 C. How many Total Other Employee(s) are not eligible or acco