CONSENT FORM FOR ELECTRONIC DISTRIBUTION OF MATERIALS

ERISA CONSENT FORM FOR ELECTRONIC DISTRIBUTION OF MATERIALS

Under the Employee Retirement Income Security Act of 1974 (ERISA) and related regulations, employee consent must be given in order to receive electronic copies of employee benefits materials in certain situations.The purpose of this notice is to inform you that is offering you the opportunity to receive electronically all notices about your employee benefits.

All notices are accessible at : https://fs17.formsite.com/RT1HUMANRESOURCESCOM/ELTRNC_BENEFIT_MATERIALS/index.html

Such notices will include (but not be limited to) newsletters, enrollment announcements, Summary Plan Descriptions (SPDs), Summaries of Material Modifications (SMMs), Summary Annual Reports (SARs), COBRA notices, Summaries of Benefits and Coverage, Health Insurance Marketplace Notices and HIPAA certificates of creditable coverage.

Each benefit plan in which you enroll has a Summary Plan Description (SPD) that describes the key provisions of the plan. Plan amendments describe any material changes made to the benefit plan since its SPD was originally drafted. A plan’s SPD and plan amendments are very important documents.

In order for us to provide you with this opportunity, you must consent to receive all Employee Benefit notices electronically by signing the form below. Prior to consenting, you should understand that:

• When a new benefit notice, announcement, newsletter, SPD or other document is posted to the Internet, you will receive a notification at the email address you provide to inform you of the availability of the document.

• You have the right to withdraw your consent to electronic distribution at any time at no charge to you. To withdraw consent, you must notify Micheal Manning, Corporate Benefits Specialist in writing or by email-michael.manning@responseteam1.com.

• If you consent to electronic distribution, you may still request a paper version of any document free of charge.

• All benefit notices, including SPDs and plan amendments, will be available on the Internet as .PDF format. If you do not have access to the Internet, or if you do not have the programs necessary to view this type of file, you should not consent.

• To withdraw your consent or update your email address, please contact Micheal Manning, Corporate Benefits Specialist in writing or by email-michael.manning@responseteam1.com.

___________________________________________________________________________________________________

I consent to the electronic disclosure of all Employee Benefit notices, including Summary Plan Descriptions and plan amendments.

I acknowledge that I have read the contents of this notice and understand that I am entitled to withdraw my consent at any time at no cost to myself. I understand that I have the right to receive paper copies of all Employee Benefit notices, including Summary Plan Descriptions and plan amendments, upon request at no additional charge. I also confirm that I have the ability and the necessary equipment and software to access the Electronic Employee Benefit Materials & Disclosures Website, view the documents and print copies.

First Name *

Last Name *

I consent to receive electronic delivery of Employee Benefit Notices to the following address:

I wish to receive Employee Benefit Notices electronically? *

Enter Email Address Where You'd Like Employee Benefit Notices Sent *

Please enter the physical address where you'd like your Employee Benefit Notices to be mailed to.

Street Address *

City *

State *

Zip Code *

Date Signed * +

Employee Signature *

clear