Common use of Authority of Trustees Clause in Contracts

Authority of Trustees. The undersigned Employer acknowledges and agrees that all Trustees appointed under the Trust Agreement shall have all rights and powers described here under and as set forth in the Trust Agreement. Third Party Administrator – The undersigned Employer agrees that the Trust may select one or more service providers to act as a third-party administrator (“TPA”) for the Trust and/or the Welfare Benefits Plans, and that such service providers may be one or more of the Member Companies. Contributions – The undersigned Employer agrees to pay the contributions established by the Trust. The undersigned Employer further understands and agrees that benefits for employees shall not be provided by the Trust during any month for which contributions are not paid. Termination – This Adoption Agreement may be terminated by the undersigned Employer, which may withdraw from participation in the Trust by giving thirty (30) days written notice of intent to withdraw to the Trustees in accordance with the Trust Agreement. Such Member Company shall have the rights and duties specified therein. This Agreement may be terminated by the Trust, in the event that the undersigned Employer (a) shall fail or refuse to pay contributions due to the Trust in accordance with the Trust Agreement, or (b) shall be in breach of any of its other obligations under the Trust Agreement of this Adoption Agreement, which breach shall not have been cured within ten (10) days after the undersigned Employer receipt of written notice thereof. Indemnity – The undersigned Employer does hereby indemnify and hold harmless the Trustees and the Sponsor from any and all loss, damages or liability incurred in the course and scope of their respective duties as described in this Agreement, except those resulting from their gross negligence, willful misconduct or dishonesty. In the event that the Trustees or the Sponsor are made a party to any legal proceeding of any kind or nature arising out of their respective duties hereunder, directly or indirectly, the undersigned Employer agrees to indemnify and hold them harmless from any and all liability and expenses (including reasonable attorneys’ fees) resulting there from. Any damages assessed or expenses required to be paid or incurred by reason of this indemnification shall be borne equally by all Member Companies, unless it shall be determined that the damages, expenses or losses incurred result directly from the actions or inactions of a specific Member Company, its employees or producers. In such event, that specific Member Company shall be primarily responsible for payment, with other Member Companies being responsible only in the event of the specific Member Company’s inability by reason of financial insolvency to respond. Governing Law – This Agreement shall be construed and enforced in accordance with ERISA and, to the extent applicable, the laws of the State of Washington. Anti-Fraud Statement I have provided these answers as part of the application procedure required by the issuer to enroll in coverage and I agree that all information completed on this application is true, correct, and complete. It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. I understand that the issuer will rely on each answer in making coverage and rating determinations. If the issuer continues the Contract with the Group after untrue, incorrect, or incomplete information is found to have been provided, and if as a result of correcting false information the Group no longer qualifies for the Rate quoted, I understand that the issuer will have the right to adjust the rates to the appropriate level retroactive to the date the misrepresentation occurred, and the Group will be required to pay the Rate adjustment within 30 days of the date of notice by the issuer. In addition, the issuer will have the right to collect any claims payments or other damages. Group Signature Section Signature & Title of Employer Representative Date Insurance Producer Application A business applying for insurance coverage through the Washington Technology Industry Employee Benefit Trust may appoint its own Insurance Producer to represent them as noted below: Name of Insurance Producer: Name of Producer’s Agency: Street Address: City, State, Zip Code: Phone Number: Fax Number: E-Mail Address: We request the above-named producer be given access to our records in the online enrollment system, XXXXX. (Employer must complete separate SIMON authorization form. Our third-party administrator will send the form to your SIMON portal contact.) We hereby appoint the above-named Insurance Producer as our firm’s Producer of Record. This agreement will serve as notice of cancellation of any previous Insurance Producer agreement. This new appointment will remain effective until written notice is given by either party of a change. No changes may be made retroactively. Name of Employer Signature of Employer Representative Date Name & Title (PRINTED) of Employer Representative Coverage Underwritten By: Medical & Dental Insurance Benefits: Premera Blue Cross, 0000 000xx Xx XX, Xxxxxxxxx Xxxxxxx, XX 00000- 0000 Vision Insurance Benefits: VSP Vision Care, Inc., 0000 Xxxxxxx Xxxxx, Xxxxxx Xxxxxxx, XX 00000 Life Insurance Benefits: Metropolitan Life Insurance Co., 000 Xxxx Xxxxxx, Xxx Xxxx, XX 00000 Navia Benefit Solutions: 000 Xxxxxx Xxxxxx XX, Xxxxxx, XX 00000

Authority of Trustees. The undersigned Employer acknowledges and agrees that all Trustees appointed under the Trust Agreement shall have all rights and powers described here under and as set forth in the Trust Agreement. Third Party Administrator – The undersigned Employer agrees that the Trust may select one or more service providers to act as a third-third party administrator (“TPA”) for the Trust and/or the Welfare Benefits Plans, and that such service providers may be one or more a member of the Member CompaniesAZTC. Contributions – The undersigned Employer agrees to pay the contributions established by the Trust. The undersigned Employer further understands and agrees that benefits for employees shall not be provided by the Trust during any month for which contributions are not paid. Termination – This Adoption Agreement may be terminated by the undersigned Employer, which may withdraw from participation in the Trust by giving thirty (30) days written notice of intent to withdraw to the Trustees in accordance with the Trust terminate this Agreement. Such Member Company Employer shall have the rights and duties specified thereinin the Trust Agreement. This Agreement may be terminated by the Trust, in the event that the undersigned Employer (a) shall fail fails or refuse refuses to pay contributions due to the Trust in accordance with the Trust AgreementTrust, or (b) shall be in breach of any of its other obligations under the Trust Agreement of this Adoption Agreement, which breach shall not have been cured within ten (10) days after the undersigned Employer receipt of written notice thereof. Indemnity – The undersigned Employer does hereby indemnify and hold harmless the Trust, its Trustees and the Sponsor from any and all loss, damages or liability incurred in the course and scope of their respective duties as described in this Agreement, except those resulting from their gross the undersigned Employer’s negligence, willful misconduct misrepresentation, breach of contract or dishonesty. In the event that the Trust, its Trustees or the Sponsor are made a party to any legal proceeding arising from the undersigned Employer’s negligence, misrepresentation, breach of any kind contract or nature arising out of their respective duties hereunder, directly or indirectlydishonesty, the undersigned Employer agrees to indemnify and hold them harmless from any and all liability and expenses (including reasonable attorneys’ fees) resulting there from. Any damages assessed or expenses required to be paid or incurred by reason of this indemnification shall be borne equally by all Member Companies, unless it shall be determined that the damages, expenses or losses incurred result directly from the actions or inactions of a specific Member Company, its employees or producers. In such event, that specific Member Company shall be primarily responsible for payment, with other Member Companies being responsible only in the event of the specific Member Company’s inability by reason of financial insolvency to respondtherefrom. Governing Law – This Agreement shall be construed and enforced in accordance with ERISA and, to the extent applicable, the laws of the State of WashingtonArizona. Anti-Fraud Statement I have provided these answers as part of the application procedure required by the issuer to enroll in coverage and I agree that all information completed on this application is true, correct, and complete. It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. I understand that the issuer will rely on each answer in making coverage and rating determinations. If the issuer continues the Contract with the Group after untrue, incorrect, or incomplete information is found to have been provided, and if as a result of correcting false information the Group no longer qualifies for the Rate quoted, I understand that the issuer will have the right to adjust the rates to the appropriate level retroactive to the date the misrepresentation occurred, and the Group will be required to pay the Rate adjustment within 30 days of the date of notice by the issuer. In addition, the issuer will have the right to collect any claims payments or other damages. Group Signature Section Signature & Title of Employer Representative Date Insurance Producer Broker & General Agent Application A business applying for insurance coverage through the Washington Arizona Technology Industry Council Employee Benefit Trust may appoint its own Insurance Producer Broker and/or General Agent to represent them as noted below: Broker Name: General Agent’s Name of Insurance Producer(if applicable): Agency: Name of Producer’s Agency: Street Address: Street Address: City, State, Zip CodeZip: Phone Number: Fax NumberCity, State, Zip: E-Mail Addressmail: E-mail: ☐ We request the above-named producer broker be given access to our records in the online enrollment system, SIMON. (Employer must complete separate SIMON authorization form. Our third-party administrator will send the form to your SIMON portal contact.) ☐ We request the above-named general agent be given access to our records in the online enrollment system, XXXXX. (Employer must complete separate SIMON authorization form. Our third-party administrator will send the form to your SIMON portal contact.) We hereby appoint the above-named Insurance Producer Broker and/or General Agent as our firm’s Producer Broker and/or General Agent of Record. This agreement will serve as notice of cancellation of any previous Insurance Producer Broker and/or General Agent agreement. This new appointment will remain effective until written notice is given by either party of a change. No changes may be made retroactively. Name of Employer Signature of Employer Representative Date Name & Title (PRINTEDPrinted) of Employer Representative Coverage Underwritten By: Medical & Dental Insurance Benefits: Premera Blue Cross, 0000 000xx Xx XX, Xxxxxxxxx Xxxxxxx, XX 00000- 0000 Vision Insurance Benefits: VSP Vision Care, Inc., 0000 Xxxxxxx Xxxxx, Xxxxxx Xxxxxxx, XX 00000 Life Insurance Benefits: Metropolitan Life Insurance Co., 000 Xxxx Xxxxxx, Xxx Xxxx, XX 00000 Navia Benefit Solutions: 000 Xxxxxx Xxxxxx XX, Xxxxxx, XX 00000:

Authority of Trustees. The undersigned Employer acknowledges and agrees that all Trustees appointed under the Trust Agreement shall have all rights and powers described here under and as set forth in the Trust Agreement. Third Party Administrator – The undersigned Employer agrees that the Trust may select one or more service providers to act as a third-party administrator (“TPA”) for the Trust and/or the Welfare Benefits Plans, and that such service providers may be one or more of the Member Companies. Contributions – The undersigned Employer agrees to pay the contributions established by the Trust. The undersigned Employer further understands and agrees that benefits for employees shall not be provided by the Trust during any month for which contributions are not paid. Termination – This Adoption Agreement may be terminated by the undersigned Employer, which may withdraw from participation in the Trust by giving thirty (30) days written notice of intent to withdraw to the Trustees in accordance with the Trust Agreement. Such Member Company shall have the rights and duties specified therein. This Agreement may be terminated by the Trust, in the event that the undersigned Employer (a) shall fail or refuse to pay contributions due to the Trust in accordance with the Trust Agreement, or (b) shall be in breach of any of its other obligations under the Trust Agreement of this Adoption Agreement, which breach shall not have been cured within ten (10) days after the undersigned Employer receipt of written notice thereof. Indemnity – The undersigned Employer does hereby indemnify and hold harmless the Trustees and the Sponsor from any and all loss, damages or liability incurred in the course and scope of their respective duties as described in this Agreement, except those resulting from their gross negligence, willful misconduct or dishonesty. In the event that the Trustees or the Sponsor are made a party to any legal proceeding of any kind or nature arising out of their respective duties hereunder, directly or indirectly, the undersigned Employer agrees to indemnify and hold them harmless from any and all liability and expenses (including reasonable attorneys’ fees) resulting there from. Any damages assessed or expenses required to be paid or incurred by reason of this indemnification shall be borne equally by all Member Companies, unless it shall be determined that the damages, expenses or losses incurred result directly from the actions or inactions of a specific Member Company, its employees or producers. In such event, that specific Member Company shall be primarily responsible for payment, with other Member Companies being responsible only in the event of the specific Member Company’s inability by reason of financial insolvency to respond. Governing Law – This Agreement shall be construed and enforced in accordance with ERISA and, to the extent applicable, the laws of the State of Washington. Anti-Fraud Statement I have provided these answers as part of the application procedure required by the issuer to enroll in coverage and I agree that all information completed on this application is true, correct, and complete. It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. I understand that the issuer will rely on each answer in making coverage and rating determinations. If the issuer continues the Contract with the Group after untrue, incorrect, or incomplete information is found to have been provided, and if as a result of correcting false information the Group no longer qualifies for the Rate quoted, I understand that the issuer will have the right to adjust the rates to the appropriate level retroactive to the date the misrepresentation occurred, and the Group will be required to pay the Rate adjustment within 30 days of the date of notice by the issuer. In addition, the issuer will have the right to collect any claims payments or other damages. Group Signature Section Date Signature & Title of Employer Representative Date Group Signature Section Insurance Producer Application A business applying for insurance coverage through the Washington Technology Industry Employee Benefit Trust may appoint its own Insurance Producer to represent them as noted below: Name of Insurance Producer: Name of Producer’s Agency: Street Address: City, State, Zip Code: Phone Number: Fax Number: E-Mail Address: q We request the above-named producer be given access to our records in the online enrollment system, XXXXX. (Employer must complete separate SIMON authorization form. Our third-party administrator will send the form to your SIMON portal contact.) We hereby appoint the above-named Insurance Producer as our firm’s Producer of Record. This agreement will serve as notice of cancellation of any previous Insurance Producer agreement. This new appointment will remain effective until written notice is given by either party of a change. No changes may be made retroactively. Name of Employer Signature of Employer Representative Date Name & Title (PRINTED) of Employer Representative Coverage Underwritten By: Medical & Dental Insurance Benefits: Premera Blue Cross, 0000 000xx Xx XX, Xxxxxxxxx Xxxxxxx, XX 00000- 00000-0000 Vision Insurance Benefits: VSP Vision Care, Inc., 0000 Xxxxxxx Xxxxx, Xxxxxx Xxxxxxx, XX 00000 Life Insurance Benefits: Metropolitan Life Insurance Co., 000 Xxxx Xxxxxx, Xxx Xxxx, XX 00000 Navia Benefit Solutions: 000 Xxxxxx Xxxxxx XX, Xxxxxx, XX 00000 Employee Assistance Program: WellSpring Family Services, 0000 Xxxxxxx Xxx X, Xxxxxxx, XX 00000

Authority of Trustees. The undersigned Employer acknowledges and agrees that all Trustees appointed under the Trust Agreement shall have all rights and powers described here under and as set forth in the Trust Agreement. Third Party Administrator – The undersigned Employer agrees that the Trust may select one or more service providers to act as a third-party administrator (“TPA”) for the Trust and/or the Welfare Benefits Plans, and that such service providers may be one or more of the Member Companies. Contributions – The undersigned Employer agrees to pay the contributions established by the Trust. The undersigned Employer further understands and agrees that benefits for employees shall not be provided by the Trust during any month for which contributions are not paid. Termination – This Adoption Participation Agreement may be terminated by the undersigned Employer, which may withdraw from participation in the Trust by giving thirty (30) days written notice of intent to withdraw to the Trustees of its intent to withdraw, in accordance with the Trust Agreement. Such Member Company Employer shall have the rights and duties specified therein. This Agreement may be terminated by the Trust as provided in the Trust, in the event that including but not limited to, the undersigned Employer Employer’s (a) shall fail failure or refuse refusal to pay contributions due to the Trust in accordance with the Trust Agreement, (b) fraud or other intentional misrepresentation of material fact, or (b) shall be in breach of any of its other obligations under the Trust Agreement or of this Adoption Participation Agreement, which breach shall not have been cured within ten (10) days after the undersigned Employer Employer’s receipt of written notice thereof. Indemnity – The undersigned Employer does hereby indemnify and hold harmless the Trustees and the Sponsor from any and all loss, damages or liability incurred in the course and scope of their respective duties as described in this AgreementAgreement and the Trust, except those resulting from their the Trustee’s or Sponsor’s own gross negligence, willful misconduct or dishonesty. In the event that the Trustees or the Sponsor are made a party to any legal proceeding of any kind or nature arising out of their respective duties hereunder, directly or indirectly, the undersigned Employer agrees to indemnify and hold them harmless from any and all liability and expenses (including reasonable attorneys’ fees) resulting there from. Any damages assessed or expenses required to be paid or incurred by reason of this indemnification The indemnity provided hereunder shall be borne equally by joint and several with all Member Companies, unless it shall be determined that the damages, expenses or losses incurred result directly from the actions or inactions of a specific Member Company, its employees or producers. In such event, that specific Member Company shall be primarily responsible for payment, with other Member Companies being responsible only in the event of the specific Member Company’s inability by reason of financial insolvency to respondother Participating Employers under the Trust. Governing Law – This Agreement shall be construed and enforced in accordance with ERISA and, to the extent applicable, the laws of the State of WashingtonArizona. Anti-Fraud Statement I have provided these answers as part of the application procedure required by the issuer to enroll in coverage and I agree that all information completed on this application is true, correct, and complete. It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. I understand that the issuer will rely on each answer in making coverage and rating determinations. If the issuer continues the Contract with the Group after untrue, incorrect, or incomplete information is found to have been provided, and if as a result of correcting false information the Group no longer qualifies for the Rate quoted, I understand that the issuer will have the right to adjust the rates to the appropriate level retroactive to the date the misrepresentation occurred, and the Group will be required to pay the Rate adjustment within 30 days of the date of notice by the issuer. In addition, the issuer will have the right to collect any claims payments or other damages. Group Signature Section Date Signature & Title of Employer Representative Date Group Signature Section Insurance Producer Broker & General Agent Application A business applying for insurance coverage through the Washington Arizona Technology Industry Council Employee Benefit Trust may appoint its own Insurance Producer Broker and/or General Agent to represent them as noted below: Broker Name: General Agent’s Name of Insurance Producer(if applicable): Agency: Name of Producer’s Agency: Street Address: Street Address: City, State, Zip CodeZip: Phone Number: Fax NumberCity, State, Zip: E-Mail Addressmail: E-mail: ☐ We request the above-named producer broker be given access to our records in the online enrollment system, XXXXX. (Employer must complete separate SIMON authorization form. Our third-party administrator will send the form to your SIMON portal contact.) ☐ We request the above-named general agent be given access to our records in the online enrollment system, XXXXX. (Employer must complete separate SIMON authorization form. Our third-party administrator will send the form to your SIMON portal contact.) We hereby appoint the above-named Insurance Producer Broker and/or General Agent as our firm’s Producer Broker and/or General Agent of Record. This agreement will serve as notice of cancellation of any previous Insurance Producer Broker and/or General Agent agreement. This new appointment will remain effective until written notice is given by either party of a change. No changes may be made retroactively. Name of Employer Signature of Employer Representative Date Name & Title (PRINTEDPrinted) of Employer Representative Coverage Underwritten By: Medical & Dental Insurance Benefits: Premera Blue CrossCross Blue Shield of Arizona, 0000 000xx Xx XXX Xxx Xxxxxxxxxx Xx., Xxxxxxxxx Xxxxxxx, XX 00000- 0000 00000 Vision Insurance Benefits: VSP Vision Care, Inc., 0000 Xxxxxxx Xxxxx, Xxxxxx Xxxxxxx, XX 00000 Life Insurance Benefits: Metropolitan Life Insurance Co., 000 Xxxx Xxxxxx, Xxx Xxxx, XX 00000 Navia Benefit Solutions: 000 Xxxxxx Xxxxxx XX, Xxxxxx, XX 00000 Employee Assistance Program: WellSpring Family Services, 0000 Xxxxxxx Xxx X, Xxxxxxx, XX 00000

Authority of Trustees. The undersigned Employer acknowledges and agrees that all Trustees appointed under the Trust Agreement shall have all rights and powers described here under and as set forth in the Trust Agreement. Third Party Administrator – The undersigned Employer agrees that the Trust may select one or more service providers to act as a third-party administrator (“TPA”) for the Trust and/or the Welfare Benefits Plans, and that such service providers may be one or more of the Member Companies. Contributions – The undersigned Employer agrees to pay the contributions established by the Trust. The undersigned Employer further understands and agrees that benefits for employees shall not be provided by the Trust during any month for which contributions are not paid. Termination – This Adoption Agreement may be terminated by the undersigned Employer, which may withdraw from participation in the Trust by giving thirty (30) days written notice of intent to withdraw to the Trustees in accordance with the Trust Agreement. Such Member Company shall have the rights and duties specified therein. This Agreement may be terminated by the Trust, in the event that the undersigned Employer (a) shall fail or refuse to pay contributions due to the Trust in accordance with the Trust Agreement, or (b) shall be in breach of any of its other obligations under the Trust Agreement of this Adoption Agreement, which breach shall not have been cured within ten (10) days after the undersigned Employer receipt of written notice thereof. Indemnity – The undersigned Employer does hereby indemnify and hold harmless the Trustees and the Sponsor from any and all loss, damages or liability incurred in the course and scope of their respective duties as described in this Agreement, except those resulting from their gross negligence, willful misconduct or dishonesty. In the event that the Trustees or the Sponsor are made a party to any legal proceeding of any kind or nature arising out of their respective duties hereunder, directly or indirectly, the undersigned Employer agrees to indemnify and hold them harmless from any and all liability and expenses (including reasonable attorneys’ fees) resulting there from. Any damages assessed or expenses required to be paid or incurred by reason of this indemnification shall be borne equally by all Member Companies, unless it shall be determined that the damages, expenses or losses incurred result directly from the actions or inactions of a specific Member Company, its employees or producers. In such event, that specific Member Company shall be primarily responsible for payment, with other Member Companies being responsible only in the event of the specific Member Company’s inability by reason of financial insolvency to respond. Governing Law – This Agreement shall be construed and enforced in accordance with ERISA and, to the extent applicable, the laws of the State of Washington. Anti-Fraud Statement I have provided these answers as part of the application procedure required by the issuer to enroll in coverage and I agree that all information completed on this application is true, correct, and complete. It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. I understand that the issuer will rely on each answer in making coverage and rating determinations. If the issuer continues the Contract with the Group after untrue, incorrect, or incomplete information is found to have been provided, and if as a result of correcting false information the Group no longer qualifies for the Rate quoted, I understand that the issuer will have the right to adjust the rates to the appropriate level retroactive to the date the misrepresentation occurred, and the Group will be required to pay the Rate adjustment within 30 days of the date of notice by the issuer. In addition, the issuer will have the right to collect any claims payments or other damages. Group Signature Section Signature & Title of Employer Representative Date Insurance Producer Application A business applying for insurance coverage through the Washington Technology Industry Employee Benefit Trust may appoint its own Insurance Producer to represent them as noted below: Name of Insurance Producer: Name of Producer’s Agency: Street Address: City, State, Zip Code: Phone Number: Fax Number: E-Mail Address: ❑ We request the above-named producer be given access to our records in the online enrollment system, XXXXX. (Employer must complete separate SIMON authorization form. Our third-party administrator will send the form to your SIMON portal contact.) We hereby appoint the above-named Insurance Producer as our firm’s Producer of Record. This agreement will serve as notice of cancellation of any previous Insurance Producer agreement. This new appointment will remain effective until written notice is given by either party of a change. No changes may be made retroactively. Name of Employer Signature of Employer Representative Date Name & Title (PRINTED) of Employer Representative Coverage Underwritten By: Medical & Dental Insurance Benefits: Premera Blue Cross, 0000 000xx Xx XX, Xxxxxxxxx Xxxxxxx, XX 00000- 00000-0000 Vision Insurance Benefits: VSP Vision Care, Inc., 0000 Xxxxxxx Xxxxx, Xxxxxx Xxxxxxx, XX 00000 Life Insurance Benefits: Metropolitan Life Insurance Co., 000 Xxxx Xxxxxx, Xxx Xxxx, XX 00000 Navia Benefit Solutions: 000 Xxxxxx Xxxxxx XX, Xxxxxx, XX 00000

Authority of Trustees. The undersigned Employer acknowledges and agrees that all Trustees appointed under the Trust Agreement shall have all rights and powers described here under and as set forth in the Trust Agreement. Third Party Administrator – The undersigned Employer agrees that the Trust may select one or more service providers to act as a third-party administrator (“TPA”) for the Trust and/or the Welfare Benefits Plans, and that such service providers may be one or more of the Member Companies. Contributions – The undersigned Employer agrees to pay the contributions established by the Trust. The undersigned Employer further understands and agrees that benefits for employees shall not be provided by the Trust during any month for which contributions are not paid. Termination – This Adoption Agreement may be terminated by the undersigned Employer, which may withdraw from participation in the Trust by giving thirty (30) days written notice of intent to withdraw to the Trustees in accordance with the Trust Agreement. Such Member Company shall have the rights and duties specified therein. This Agreement may be terminated by the Trust, in the event that the undersigned Employer (a) shall fail or refuse to pay contributions due to the Trust in accordance with the Trust Agreement, or (b) shall be in breach of any of its other obligations under the Trust Agreement of this Adoption Agreement, which breach shall not have been cured within ten (10) days after the undersigned Employer receipt of written notice thereof. Indemnity – The undersigned Employer does hereby indemnify and hold harmless the Trustees and the Sponsor from any and all loss, damages or liability incurred in the course and scope of their respective duties as described in this Agreement, except those resulting from their gross negligence, willful misconduct or dishonesty. In the event that the Trustees or the Sponsor are made a party to any legal proceeding of any kind or nature arising out of their respective duties hereunder, directly or indirectly, the undersigned Employer agrees to indemnify and hold them harmless from any and all liability and expenses (including reasonable attorneys’ fees) resulting there from. Any damages assessed or expenses required to be paid or incurred by reason of this indemnification shall be borne equally by all Member Companies, unless it shall be determined that the damages, expenses or losses incurred result directly from the actions or inactions of a specific Member Company, its employees or producers. In such event, that specific Member Company shall be primarily responsible for payment, with other Member Companies being responsible only in the event of the specific Member Company’s inability by reason of financial insolvency to respond. Governing Law – This Agreement shall be construed and enforced in accordance with ERISA and, to the extent applicable, the laws of the State of Washington. Anti-Fraud Statement I have provided these answers as part of the application procedure required by the issuer to enroll in coverage and I agree that all information completed on this application is true, correct, and complete. It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. I understand that the issuer will rely on each answer in making coverage and rating determinations. If the issuer continues the Contract with the Group after untrue, incorrect, or incomplete information is found to have been provided, and if as a result of correcting false information the Group no longer qualifies for the Rate quoted, I understand that the issuer will have the right to adjust the rates to the appropriate level retroactive to the date the misrepresentation occurred, and the Group will be required to pay the Rate adjustment within 30 days of the date of notice by the issuer. In addition, the issuer will have the right to collect any claims payments or other damages. Group Signature Section Signature & Title of Employer Representative Date Insurance Producer Application A business applying for insurance coverage through the Washington Technology Industry Employee Benefit Trust may appoint its own Insurance Producer to represent them as noted below: Name of Insurance Producer: Name of Producer’s Agency: Street Address: City, State, Zip Code: Phone Number: Fax Number: E-Mail Address: ❑ We request the above-named producer be given access to our records in the online enrollment system, XXXXX. (Employer must complete separate SIMON authorization form. Our third-party administrator will send the form to your SIMON portal contact.) We hereby appoint the above-named Insurance Producer as our firm’s Producer of Record. This agreement will serve as notice of cancellation of any previous Insurance Producer agreement. This new appointment will remain effective until written notice is given by either party of a change. No changes may be made retroactively. Name of Employer Signature of Employer Representative Date Name & Title (PRINTED) of Employer Representative Coverage Underwritten By: Medical & Dental Insurance Benefits: Premera Blue Cross, 0000 000xx Xx XX, Xxxxxxxxx Xxxxxxx, XX 00000- 0000 Vision Insurance Benefits: VSP Vision Care, Inc., 0000 Xxxxxxx Xxxxx, Xxxxxx Xxxxxxx, XX 00000 Life Insurance Benefits: Metropolitan Life Insurance Co., 000 Xxxx Xxxxxx, Xxx Xxxx, XX 00000 Navia Benefit Solutions: 000 Xxxxxx Xxxxxx XX, Xxxxxx, XX 00000:

Authority of Trustees. The undersigned Employer acknowledges and agrees that all Trustees appointed under the Trust Agreement shall have all rights and powers described here under and as set forth in the Trust Agreement. Third Party Administrator – The undersigned Employer agrees that the Trust may select one or more service providers to act as a third-party administrator (“TPA”) for the Trust and/or the Welfare Benefits Plans, and that such service providers may be one or more of the Member Companies. Contributions – The undersigned Employer agrees to pay the contributions established by the Trust. The undersigned Employer further understands and agrees that benefits for employees shall not be provided by the Trust during any month for which contributions are not paid. Termination – This Adoption Agreement may be terminated by the undersigned Employer, which may withdraw from participation in the Trust by giving thirty (30) days written notice of intent to withdraw to the Trustees in accordance with the Trust Agreement. Such Member Company shall have the rights and duties specified therein. This Agreement may be terminated by the Trust, in the event that the undersigned Employer (a) shall fail or refuse to pay contributions due to the Trust in accordance with the Trust Agreement, or (b) shall be in breach of any of its other obligations under the Trust Agreement of this Adoption Agreement, which breach shall not have been cured within ten (10) days after the undersigned Employer receipt of written notice thereof. Indemnity – The undersigned Employer does hereby indemnify and hold harmless the Trustees and the Sponsor from any and all loss, damages or liability incurred in the course and scope of their respective duties as described in this Agreement, except those resulting from their gross negligence, willful misconduct or dishonesty. In the event that the Trustees or the Sponsor are made a party to any legal proceeding of any kind or nature arising out of their respective duties hereunder, directly or indirectly, the undersigned Employer agrees to indemnify and hold them harmless from any and all liability and expenses (including reasonable attorneys’ fees) resulting there from. Any damages assessed or expenses required to be paid or incurred by reason of this indemnification shall be borne equally by all Member Companies, unless it shall be determined that the damages, expenses or losses incurred result directly from the actions or inactions of a specific Member Company, its employees or producers. In such event, that specific Member Company shall be primarily responsible for payment, with other Member Companies being responsible only in the event of the specific Member Company’s inability by reason of financial insolvency to respond. Governing Law – This Agreement shall be construed and enforced in accordance with ERISA and, to the extent applicable, the laws of the State of Washington. Anti-Fraud Statement I have provided these answers as part of the application procedure required by the issuer to enroll in coverage and I agree that all information completed on this application is true, correct, and complete. It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. I understand that the issuer will rely on each answer in making coverage and rating determinations. If the issuer continues the Contract with the Group after untrue, incorrect, or incomplete information is found to have been provided, and if as a result of correcting false information the Group no longer qualifies for the Rate quoted, I understand that the issuer will have the right to adjust the rates to the appropriate level retroactive to the date the misrepresentation occurred, and the Group will be required to pay the Rate adjustment within 30 days of the date of notice by the issuer. In addition, the issuer will have the right to collect any claims payments or other damages. Group Signature Section Signature & Title of Employer Representative Date Insurance Producer Application A business applying for insurance coverage through the Washington Technology Industry Employee Benefit Trust may appoint its own Insurance Producer to represent them as noted below: Name of Insurance Producer: Name of Producer’s Agency: Street Address: City, State, Zip Code: Phone Number: Fax Number: E-Mail Address: ❑ We request the above-named producer be given access to our records in the online enrollment system, XXXXX. (Employer must complete separate SIMON authorization form. Our third-party administrator will send the form to your SIMON portal contact.) We hereby appoint the above-named Insurance Producer as our firm’s Producer of Record. This agreement will serve as notice of cancellation of any previous Insurance Producer agreement. This new appointment will remain effective until written notice is given by either party of a change. No changes may be made retroactively. Name of Employer Signature of Employer Representative Date Name & Title (PRINTED) of Employer Representative Coverage Underwritten By: Medical & Dental Insurance Benefits: Premera Blue Cross, 0000 000xx Xx XX, Xxxxxxxxx Xxxxxxx, XX 00000- 00000-0000 Vision Insurance Benefits: VSP Vision Care, Inc., 0000 Xxxxxxx Xxxxx, Xxxxxx Xxxxxxx, XX 00000 Life Insurance Benefits: Metropolitan Life Insurance Co., 000 Xxxx Xxxxxx, Xxx Xxxx, XX 00000 Navia Benefit Solutions: 000 Xxxxxx Xxxxxx XX, Xxxxxx, XX 00000

Authority of Trustees. The undersigned Employer acknowledges and agrees that all Trustees appointed under the Trust Agreement shall have all rights and powers described here under and as set forth in the Trust Agreement. Third Party Administrator – The undersigned Employer agrees that the Trust may select one or more service providers to act as a third-party administrator (“TPA”) for the Trust and/or the Welfare Benefits Plans, and that such service providers may be one or more a member of the Member CompaniesWTIA. Contributions – The undersigned Employer agrees to pay the contributions established by the Trust. The undersigned Employer further understands and agrees that benefits for employees shall not be provided by the Trust during any month for which contributions are not paid. Termination – This Adoption Agreement may be terminated by the undersigned Employer, which may withdraw from participation in the Trust by giving thirty (30) days written notice of intent to withdraw to the Trustees in accordance with the Trust terminate this Agreement. Such Member Company Employer shall have the rights and duties specified thereinin the Trust Agreement. This Agreement may be terminated by the Trust, in the event that the undersigned Employer (a) shall fail or refuse to pay contributions due to the Trust in accordance with the Trust AgreementTrust, or (b) shall be in breach of any of its other obligations under the Trust Agreement of this Adoption Agreement, which breach shall not have been cured within ten (10) days after the undersigned Employer receipt of written notice thereof. Indemnity – The undersigned Employer does hereby indemnify and hold harmless the Trust, its Trustees and the Sponsor from any and all loss, damages or liability incurred in the course and scope of their respective duties as described in this Agreement, except those resulting from their gross the undersigned Employer's negligence, willful misconduct misrepresentation, breach of contract or dishonesty. In the event that the Trust, its Trustees or the Sponsor are made a party to any legal proceeding arising from the undersigned Employer's negligence, misrepresentation, breach of any kind contract or nature arising out of their respective duties hereunder, directly or indirectlydishonesty, the undersigned Employer agrees to indemnify and hold them harmless from any and all liability and expenses (including reasonable attorneys’ ' fees) resulting there from. Any damages assessed or expenses required to be paid or incurred by reason of this indemnification shall be borne equally by all Member Companies, unless it shall be determined that the damages, expenses or losses incurred result directly from the actions or inactions of a specific Member Company, its employees or producers. In such event, that specific Member Company shall be primarily responsible for payment, with other Member Companies being responsible only in the event of the specific Member Company’s inability by reason of financial insolvency to respondtherefrom. Governing Law – - This Agreement shall be construed and enforced in accordance with ERISA and, to the extent applicable, the laws of the State of Washington. Anti-Fraud Statement I have provided these answers as part of the application procedure required by the issuer to enroll in coverage and I agree that all information completed on this application is true, correct, and complete. It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. I understand that the issuer will rely on each answer in making coverage and rating determinations. If the issuer continues the Contract with the Group after untrue, incorrect, or incomplete information is found to have been provided, and if as a result of correcting false information the Group no longer qualifies for the Rate quoted, I understand that the issuer will have the right to adjust the rates to the appropriate level retroactive to the date the misrepresentation occurred, and the Group will be required to pay the Rate adjustment within 30 days of the date of notice by the issuer. In addition, the issuer will have the right to collect any claims payments or other damages. Group Signature Section Signature & Title of Employer Representative Date Insurance Producer Application A business applying for insurance coverage through the Washington Technology Industry Employee Benefit Trust may appoint its own Insurance Producer to represent them as noted below: Name of Insurance Producer: Name of Producer’s Agency: Street Address: City, State, Zip Code: Phone Number: Fax Number: E-Mail Address: We request the above-named producer be given access to our records in the online enrollment system, XXXXX. (Employer must complete separate SIMON authorization form. Our third-party administrator will send the form to your SIMON portal contact.) We hereby appoint the above-named Insurance Producer as our firm’s Producer of Record. This agreement will serve as notice of cancellation of any previous Insurance Producer agreement. This new appointment will remain effective until written notice is given by either party of a change. No changes may be made retroactively. Name of Employer Signature of Employer Representative Date Name & Title (PRINTED) of Employer Representative Coverage Underwritten By: Medical & Dental Insurance Benefits: Premera Blue Cross, 0000 000xx Xx XX, Xxxxxxxxx Xxxxxxx, XX 00000- 0000 Vision Insurance Benefits: VSP Vision Care, Inc., 0000 Xxxxxxx Xxxxx, Xxxxxx Xxxxxxx, XX 00000 Life Insurance Benefits: Metropolitan Life Insurance Co., 000 Xxxx Xxxxxx, Xxx Xxxx, XX 00000 Navia Benefit Solutions: 000 Xxxxxx Xxxxxx XX, Xxxxxx, XX 00000: