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<br />EMPLOYEE BENEFIT PLAN <br />DISCLOSURE FORM <br /> <br />For <br /> <br />Citv of Paris <br /> <br />The agent and/or HealthCare Benefits, Inc. will contract with or represent the insurance carrier in conjunction <br />with the sale of certain group insurance polices. This disclosure does not limit the agent's ability to <br />recommend the products of other insurance companies or other funding organizations, but is intended to <br />disclose the financial interest of the parties as to the Employee Benefit Plan. HealthCare Benefits, Inc. is a <br />wholly-owned subsidiary of Blue Cross Blue Shield of Texas, Inc. As requested by the Purchaser, HealthCare <br />Benefits, Inc. has solicited bids from Stop Loss Carriers, Life Carriers, etc., and the Purchaser, after reviewing <br />the proposals, has selected certain coverage. The relationship and dealings of those companies are on file with <br />the State Board ofInsurance. If insurance is purchased through an insurance company, HealthCare Benefits, <br />Inc. may contract to facilitate the payment of insurance premiums, claims and eligibility and may receive <br />compensation for its services, but HealthCare Benefits, Inc. is not an agent of the insurance company and does <br />not receive commissions. <br /> <br />The following persons or companies are entitled to commissions as agents on the insurance contract issued <br />to you: <br /> <br />Product: Administration <br /> <br />Name of Broker: N/A <br /> <br />Commission: $000 <br /> <br />Product: Stop Loss <br /> <br />Name of Broker: N/A <br /> <br />Commission: 0% <br /> <br />HealthCare Benefits, Inc., in addition to its administrative charge as indicated in the Administrative Services <br />Agreement, is entitled to the following payments and marketing allowances for its services: <br /> <br />Product: N/A <br /> <br />Administrative Charge: N/A <br /> <br />FOR CITY OF PARIS, PURCHASER: <br /> <br />ATTEST: <br /> <br />Title: Mayor, Eric S. Clifford <br /> <br />April 8, 1996 <br />(Date) <br /> <br />Mattie Cunningham, City Clerk <br /> <br />APPROVED AS TO FORM: <br /> <br />T. K. Haynes, City Attorney <br />