Okaloosa County BOCC — August 18, 2015 — Group Flexible Benefits Plan

GROUP FLEXIBLE BENEFITS PLAN This is an Agreement between Board of County Commissioners of Okaloosa County, Florida (hereinafter referred to as the “PLAN SPONSOR” ) and Lockard & Williams Insurance Services, P.A. The Pian Service Provider (hereinafter referred to as “L&W") for Group Flexible Benefits Plan Administration HRA Administration WHEREAS, the PLAN SPONSOR has established a Group Flexible Benefits Plan and a HRA (called the pian in this Agreement) for certain of its employees; and WHEREAS, the PLAN SPONSOR has requested L&W to act as its agent with regard to the payment of certain benefits of the plan and to furnish services with respect to the plan. NOW, THEREFORE, in consideration of the mutual promises and covenants contained in this Agreement, the PLAN SPONSOR and L&W agree to the provisions as set forth in this Agreement. bl SECTION 1. PLAN - As used in this Agreement, plan means the Group Flexible Benefits Plan set forth in the plan document, together with any and all amendments and supplements thereto. SECTION 2. EFFECTIVE DATE This Agreement is effective October 1, 2015 through September 30, 2016; with an option for additional years if agreed upon and executed by both parties in writing. SECTION 3. PLAN BENEFITS SUBJECT TO THIS AGREEMENT The plan benefits subject to this Agreement are employee benefits. SECTION 4. L&W RESPONSIBILITIES (a) L&W wiil process initial election forms and revocation forms to initiate the process. (b) L&W will provide to PLAN SPONSOR reimbursement claim forms with instructions on how to complete and file. (€) L&W will issue reimbursement checks to the participants of the plan as eligible claims are received and processed. A check register for all checks that are printed will be provided to the PLAN SPONSOR. (d) L&W will provide a reimbursement file to the PLAN SPONSOR which identifies all data pertaining to each check that is issued on each specified check cycle. This information will include employee name, social security number, check number, check amount and benefit account drawn from. This file will be delivered to the PLAN SPONSOR in a time frame agreed upon by both parties. (e) L&W will administer discrimination testing and provide interpretation based on information provided by the PLAN SPONSOR. (f) L&W will provide contribution reports on an ongoing basis as the plan year progresses. Page 1 of 5 (@ (h) ) @ (1) (m) (n) (a) (b) (c) (a) (b) (a) (b) L&W will provide forms to the PLAN SPONSOR in communicating participant terminations and family status changes to L&W. L&W will prepare Form 5500 annually if needed and requested by PLAN SPONSOR. L&W will supply election forms at the end of each plan year for use in making elections for the following plan year as requested. L&W will make any amendments necessary to the plan document and summary plan description. L&W will provide each participant with a statement of account at a minimum of two times per plan year. We will also attach a memo with the final statement of each plan year for those employees that have a balance remaining in the flexible spending account. L&W will provide an annual forfeiture report to the PLAN SPONSOR. L&W will provide and initiate any amendments to the plan document ar summary plan description that may become necessary during the plan year. This will be done at no charge to the PLAN SPONSOR. L&W will maintain an amount and type of liability insurance coverage acceptable to the PLAN SPONSOR. SECTION 5. PLAN SPONSOR RESPONSIBILITIES The PLAN SPONSOR will report participant terminations and changes of family status to L&W. The PLAN SPONSOR will reconcile payroll amounts redirected to the plan based on contribution worksheets provided by L&W. If reimbursement checks are provided to the PLAN SPONSOR those checks will be signed by an authorized representative of the PLAN SPONSOR and then distributed to those employees receiving a reimbursement. SECTION 6. L&W LIABILITY L