INVOICE FREQUENCY: MAINTENANCE DEPOSIT - # MONTHS:

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It is important that the claims funding process work smoothly from both the employer and the vendor’s perspective. We have the ability to provide you numerous funding methodologies to give you flexibility and the freedom to continue to use a process similar to one you may already be using. You may even find one that will be easier to implement with your payroll and accounting areas.

Please review the options below and choose the option that works best for your group. You will receive a Service Agreement in the mail in the next few weeks that will incorporate the option you choose below.

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Allows you to send in a check or ACH to our offices at the close of each payroll representing the salary reductions just taken from participants for health or dependent care elections.

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Allows you to receive an invoice for claims paid during the invoicing cycle.

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Allows you to have the freedom to ask Benefit Strategies to manage funds associated with claims payments. We request this maintenance deposit so that we may begin immediately funding accounts and debit card transactions while awaiting your salary reductions or invoice payments. The Maintenance Deposit is a calculation based on the equivalent of either 1 or 2 months’ worth of your participants’ annual elections.

ALL FUNDS RELATED TO CLAIMS SHOULD BE MAILED TO OUR LOCKBOX:

BENEFIT STRATEGIES, LLC

PO BOX 847251

BOSTON, MA 02284-7251

PLEASE CHECK ONE:

FUNDING OPTION: MAINTENANCE

DEPOSIT - # MONTHS:

INVOICE FREQUENCY: PAYMENT DUE WITHIN:

Option A Salary Reduction 2 Not applicable At end of payroll cycle Option B Claims Paid Invoice 2 Monthly 5 days from invoice date Option C Claims Paid Invoice 1 Semi-Monthly 5 days from invoice date

Authorized Signature Date:

Title / Company Name

PLEASE SEND THIS COMPLETED FORM TO:

FLEX OPERATIONS

PO BOX 1300

MANCHESTER, NH 03105-1300

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The attached merchant code substantiation guidelines allow Benefit Strategies to monitor activity in participant accounts using our systems. We typically request receipts according to the levels indicated on these guidelines.

Many of our clients see the FlexExpress debit card as a means to provide convenience to their participants, as well as afford them easy access to their plan funds. Our responsibility is to assist you and your participants with finding a balance between debit card usage and the claims substantiation required by the IRS.

We ask that you

a) review the guidelines and accept them as presented or b) ask us how you can elect to change them as the plan sponsor.

We accept the parameters as presented. PLEASE SEND TO: FLEX OPERATIONS BENEFIT STRATEGIES, LLC PO BOX 1300 MANCHESTER, NH 03105-1300 FAX: 603-647-4668

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Merchant Code Description Max Trans. Amount Auto Review

2833Medicinal Chemicals and Botanicals Yes

2834Pharmaceutical Preparations 250Parameter Amount less than $50

Request for receipts are sent to participants with transactions above 50.01.

2835In-Vitro and N-Vitro Diagnostics Yes

3827Optical Instruments and Lenses Yes

3842Orthopedic and Prosthetic Appliances Yes

3851Eyeglasses and Eye Safety Shields Yes

4119Ambulance Services Yes

5047Dental/Lab/Medical/Opthalmic Hospital Equip & Supp Yes

5048Opthalmic Supplies Yes

5122Drugs, Drug Proprietors and Druggist Sundries 250Parameter Amount less than $50.

5300Wholesale Clubs 250Parameter Amount less than $50

5310Discount Stores 250Parameter Amount less than $50

5311Department Stores 250Parameter Amount less than $50

5411Grocery Stores, Supermarkets 250Parameter Amount less than $50.

5912Drug Stores and Pharmacies 250Parameter Amount less than $50

5964Direct Marketing - Catalog Merchant 250Parameter Amount less than $50

5965Direct Marketing - Catalog & Retail Merchant 250Parameter Amount less than $50

5969Direct Marketing, NEC 250Parameter Amount less than $50

5975Hearing Aids Yes

5976Orthopedic Goods, Prosthetic Devices Yes

8000Services-Health Services Yes

8011Doctors NEC Yes

8021Dentists, Orthodontists Yes

8031Osteopathic Physicians Yes

8041Chiropractors Yes

8042Optometrists, Opthalmologists Yes

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8043Opticians, Optical Goods & Eyeglasses Yes

8044Optical Goods and Eyeglasses Yes

8049Chiropodists, Podiatrists Yes

8050Nursing and Personal Care Facilities Yes

8052Immediate Care Facilities Yes

8059Nursing & Personal Care Facilities Yes

8060Services-Hospitals Yes

8062Hospitals Yes

8063Psychiatric Hospitals Yes

8069Specialty Hospitals, except Psychiatric Yes

8071Medical and Dental Laboratories Yes

8072Dental Laboratories Yes

8082Home Health Care Services Yes

8090Services-Misc Health & Allied Services,NEC Yes

8093Specialty Outpatient Facilities, NEC Yes

8099Medical Services & Health Practitioners, NEC Yes

Prepared by Benefit Strategies, LLC / August 2006

If AutoReview is set to yes, we accept all transactions from those vendors. Participants can only purchase eligible items through those vendors.

Max Transaction Amount: our system will only allow transactions up to this amount to go through at these vendor codes.

Auto Review: our system automatically approves amounts as specified in next column. All other transactions will be sent a request for documentation. Parameter Specifications: We choose what the system will automatically approve. We do not request substantiation for amounts less than these amounts.

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The IRS recently announced that certain types of debit card expenses could be automatically substantiated by the third party administrator handling your health care flexible spending accounts (Benefit Strategies). These types of expenses are associated with co-pays at health care providers. Benefit Strategies can auto-substantiate all co-pays associated with your health plans, to include multiples of 5 times each co-pay.

Many of our clients see the FlexExpress debit card as a means to provide convenience to their participants, as well as afford them easy access to their plan funds. Our responsibility is to assist you and your participants with finding a balance between debit card usage and the claims substantiation required by the IRS.

We ask that you provide us as many co-pay amounts as possible so we may automatically accept all transactions from the merchants associated with those co-pays (i.e. doctors, optometrists, etc.)

Please complete the form below and return it to us for processing. We look forward to continuing to provide you and your participants with the best service we can.

Co-Pay Description: Co-Pay Amount:

Sample: Plan Type: Medical Sample: Primary Care Physician

Office Visit $20.00

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Primary Care Physician Office Visit $ Specialist Office Visit $

Emergency Room $

Prescription Drug (Pharmacy) Generic

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Formulary

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Non-formulary $

Prescription Drug (Mail Order) Generic $ Formulary $ Non-formulary $ Other: $ Other: $

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Primary Care Physician Office Visit $ Specialist Office Visit $

Emergency Room $

Prescription Drug (Pharmacy) Generic

$

Formulary

$

Non-formulary $

Prescription Drug (Mail Order) Generic $ Formulary $ Non-formulary $ Other: $ Other: $

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Other: $ Other: $ Other: $ Other: $ Other: $

PLEASE SEND TO: FLEX OPERATIONS BENEFIT STRATEGIES, LLC PO BOX 1300 MANCHESTER, NH 03105-1300 FAX: 603-647-4668

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Our Employer Portal will give you on line access to our site with the ability to:

DOWNLOAD SCHEDULED REPORTS (Our standard report frequency is monthly. If you require a different cycle (i.e. weekly), please contact our office and we will customize the report frequencies for you.)

VIEW FORMS AND PUBLICATIONS VIEW PLAN INFORMATION SUBMIT REQUESTS RIGHT ON LINE

You and your HR staff can have access very quickly and easily by completing the form below and returning it to our offices. Your Account Manager may contact you if they need more information to set up your access, otherwise, you will receive an email outlining the instructions for on line access, providing you a username and separate communication with a password to log in.

Company Name:

Address:

City: State: Zip:

Main Phone: Main Fax:

Confidential Fax:

Please provide internet access to:

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COONNTTAACCTT11:: CONTACT TYPE: (i.e. HR, Payroll, Accounting)

NAME: CONTACT TITLE:

PHONE: EMAIL:

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COONNTTAACCTT22:: CONTACT TYPE: (i.e. HR, Payroll, Accounting)

PHONE: EMAIL:

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COONNTTAACCTT33::** CONTACT TYPE: (i.e. HR, Payroll, Accounting)

PHONE: EMAIL:

*(More than three users is available…just let us know!)

PLEASE SEND THIS COMPLETED FORM TO:

FLEX OPERATIONS

PO BOX 1300

MANCHESTER, NH 03105-1300