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<br />EMPLOYEE BENEFIT PLAN <br />DISCLOSURE FORM <br /> <br />For <br /> <br />CIYf OF PARIS <br /> <br />The agent and/or TP A listed above will contract with or represent the insurance carrier in <br />conjunction with the sale of certain group insurance policies. This disclosure does not limit the <br />agent's ability to recommend the products of other insurance companies or other funding <br />organizations, but is intended to disclose the financial interest of the parties as to the employee <br />benefit plan. HealthCare Benefits, Inc. is a wholly owned subsidiary of Blue Cross and Blue Shield <br />of Texas, Inc. As requested by the Purchaser, HealthCare Benefits. Inc. has solicited bids from Stop <br />Loss, Life, etc. and the Purchaser, after reviewing the proposals has selected certain coverage. The <br />relationship and dealings of those companies are on file with the State Board of Insurance. If <br />insurance is purchased through an insurance company, HealthCare Benefits, Inc. may contract to <br />facilitate the payment of insurance premiums, claims, and eligibility and may receive compensation <br />for its services but HealthCare Benefits, Inc. is not an agent of the insurance company and does not <br />receive commissions. <br /> <br />The following persons or companies are entitled to commissions as agents on the insurance contracts <br />issued to you: <br /> <br />Product: Administration <br /> <br />Name of Agent: <br /> <br />N/A <br /> <br />Commission: N/A <br /> <br />Product: Stoploss <br /> <br />Name of Broker: <br /> <br />N/A <br /> <br />Commission: N/A <br /> <br />HealthCare Benefits, Inc. in addition to its administrative charge as indicated in the Administrative <br />Service Agreement is entitled to the following payments and marketing allowances for its services: <br /> <br />Product: <br /> <br />N/A <br /> <br />Payment: <br /> <br />N/A <br /> <br />1 <br />