Notes for Employer Adoption Agreement

ADOPTION AGREEMENT

For the

MINNESOTA SERVICE COOPERATIVES VEBA PLAN

THIS AGREEMENT, made and entered into by ______(“Employer”) hereby adopts and where appropriate ratifies the following arrangements effective ______(“Effective Date”) which have been established or entered into by ______(the “Service Cooperative”):

1)The Minnesota Service Cooperatives VEBA Plan, which together with the Employee Benefits Trust Agreement is intended to qualify as a voluntary employees’ beneficiary association under Section 501(c)(9) of the Code;

2)The Employee Benefits Trust Agreement (the “Trust”), with MG Trust appointed as Trustee;

3)The High Deductible Health Plan;

4)The Joint Powers Agreement.

Section 1. Plan Information

A.Employer hereby adopts the Minnesota Service Cooperatives VEBA Plan with the following features (select one or more):

(1) ____Postretirement Health Care Savings Arrangement (amounts payable after employee’s retirement from public employment)

(a) ______Accounts funded with accrued severance pay, vacation pay, sick pay or similar amounts following termination of employment

And/or

(b) ______Accounts funded over employee’s working life for use in retirement

(2) _____ Health Reimbursement Arrangement for Active Employees (must also select High Deductible Health Plan below)

1. If A(2) is selected, Employer hereby adopts the High Deductible Health Plan with the following features (select only one):

VEBA Plan: (select only one by checking the box next to the plan selected)

VEBA 100 PLANS

VEBA 80 PLANS

VEBA 70 PLANS

C.The Plan Year shall be from ______to ______.

Deductible amounts and out-of-pocket maximums may increase annually to keep pace with inflation.

Section 2. Employer Information.

A.Official or legal name of Employer, including district number (where relevant):

Name ______

1. Employer address:

______

______

______

C.Name, phone number, fax and email address of contact person at Employer:

Name: ______

Phone Number: ( )______

Fax Number:( )______

Email Address: ( )______

Employer will promptly notify SelectAccount of any changes in the above

Information.

SECTION 3. CONTRIBUTIONS

1. Please complete the Minnesota Service Cooperatives VEBA Program Enrollment Form (Form F7543) containing the following information:

Name, address, date of birth and Social Security number of participants who will receive contributions to individual accounts in the VEBA.

1. Please attach copy of relevant collective bargaining language or personnel policy authorizing use of VEBA and setting forth employer contributions.

1. Contributions will be submitted to SelectAccount via: (select only one)

□Automated Clearing House (ACH) funding & electronic contribution information (recommended)

1)When submitting contributions, please follow the instructions and file format sent with your welcome packet or consult with your sales representative for details.

2)ACH Required Information

I hearby authorize SelectAccount to charge our bank account through Automated Clearing House for contributions.

Bank Name ______

Type of Account ____ Checking ____ Savings

Bank Location / Branch ______

Bank ABA Number ______

Bank Routing Number ______

Please include a voided check to assure accurate setup.

Note that account funding must be initiated by you through the standard electronic file format before each ACH transaction can occur.

□Check & manual contribution information

3)When submitting contributions, please complete the Minnesota Service Cooperatives VEBA Program Contribution Form (Form F7542) detailing the name, Social Security number, and amount of contribution. This form must accompany each contribution payment.

4)Please make contribution checks payable to:

MG Trust as Trustee for the Minnesota Service Cooperatives Employee Benefits Trust

Please mail or deliver contribution checks and completed contribution forms to:

SelectAccount

Attn: Minnesota Service Cooperatives VEBA Administration

P O Box 64193

St Paul, Minnesota 55164-0193

The timeliness, adequacy and accuracy of contributions shall be the sole responsibility of Employer.

SECTION 4. INVESTMENTS

By execution of this Adoption Agreement, Employer hereby directs Trustee to provide the following investment accounts or funds under the Plan for Plan participants (or, if applicable, spouses or beneficiaries):

Base Account (Default Account)

• SelectAccount interest bearing investment account

Investment Accounts (Optional & subject to change)

• See for investment choices and information

SECTION 5. FEES.

A.Administration fees will be paid as follows (check boxes that apply):

Payable from Payable by

individual accountsthe Employer

Status:

(1)Active employees□□

(2)Former employees□□

(3)Retired employees□□

(4)Upon termination of□□

participation in the

VEBA or cessation of

employer contributions

Employer agrees to pay all fees for administration of the VEBA in the event of failure or inability to pay fees from individual accounts (for example, if accounts are depleted before fees are assessed).

Select Account will charge a claims administration fee equal to:

□$1.83 per individual account per month for administration of the VEBA, with FSA accounts administered at no additional charge.

□This fee will be billed on a monthly basis as specified above.

B.Investment account fees will be paid as follows (check boxes that apply):

Payable from Payable by

individual accountsthe Employer

Status:

(1)Active employees□□

(2)Former employees□□

(3)Retired employees□□

(4)Upon termination of□□

participation in the

VEBA or cessation

of employer contributions

Employer agrees to pay all fees for administration of the VEBA in the event of failure or inability to pay fees from individual accounts (for example, if accounts are depleted before fees are assessed).

SelectAccount will charge an investment account administration fee equal to:

□$1.50 per individual account with optional investment accounts per month. This is an all inclusive charge for all investment account sales, purchases, and ongoing reporting. No sales load will be charged on investment alternatives. Mutual funds made available for adoption by Employer as investment alternatives may charge certain management, administration, marketing and similar fees depending on the funds selected (the “expense ratio”). The expense ratio on the funds selected as of November 1, 2007, range from .51 to 1.28 basis points, and will be applied against an employee’s investment in said funds. For reference purposes, 100 basis points is equal to 1% of the amount invested. The expense ratios are subject to change as funds are added, replaced or modified.

□This fee will be billed on a monthly basis as specified above.

C.High deductible Health Plan account fees

Fees payable to the Service Cooperative and Blue Cross Blue Shield Minnesota for administration of the High Deductible Health Plan selected under Section 1(B) hereof shall be determined pursuant to the Joint Powers Agreement and Operating Agreement and assessed to the Employer in addition to the fees set forth above.

D.Renewal account fees

Fees payable to SelectAccount are guaranteed until November 1, 2010.

SECTION 6. COORDINATION WITH CAFETERIA PLAN.

The following option is available for Employers that sponsor a health flexible spending account (Health FSA) through a cafeteria plan administered by SelectAccount (select one):

(1) ______Cafeteria plan pays first. (Recommended) Eligible health expenses will be reimbursed from the cafeteria plan Health FSA until a participant’s account is exhausted. Only then will eligible health expenses be reimbursed from the participant’s VEBA account for Active Employees.

(2) ______Cafeteria plan pays second. Eligible health expenses will be reimbursed from the VEBA account for Active Employee’s until a participant’s account is exhausted. Only then will eligible health expenses be reimbursed from the participant’s cafeteria plan Health FSA.

This election shall be deemed to be automatically renewed from year to year until the Employer amends the Adoption Agreement.

SECTION 7. JOINT POWERS AGREEMENT

The VEBA and related welfare benefit plans and service agreements have been made available for adoption by Service Cooperative in accordance with the powers granted it under the Joint Powers Agreement, as permitted under Minn. Stat. Sec. 471.59, Subds. 1 and 10. Except as expressly provided herein, the rights, duties and responsibilities of Employer and Service Cooperative, and their respective board members, employees and designees, shall be governed by the Joint Powers Agreement.

The Service Cooperative recommends that Employer consult with its own legal or tax advisor before executing this Adoption Agreement.

Employer

By: ______

Its: ______

Dated: ______

SelectAccount Internal Sales & Agency Information

Accepted by: ______Date: ______

Sales Representative: ______Rep Code: _____

Agent (if applicable): ______Agent Number: _____

Agency (if applicable): ______Agency Number: _____

Marketing ID Number/MID (if applicable): ______

1

4820-0515-9682\1 11/15/2007 5:38 PM