8/2/2019 Executive Medical Reimbursement Plan

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Copyright Envision SBS. 2007. All rights reserved. Protected by the copyright laws of the United States & Canada and by international treaties. IT IS ILLEGALAND STRICTLY PROHIBITED TO DISTRIBUTE, PUBLISH, OFFER FOR SALE, LICENSE OR SUBLICENSE, GIVE OR DISCLOSE TO ANY OTHER PARTY,THIS PRODUCT IN HARD COPY OR DIGITAL FORM. ALL OFFENDERS WILL BE SUED IN A COURT OF LAW.

Executive Medical Reimbursement Plan Page 1 of 2

EXECUTIVE MEDICAL REIMBURSEMENT PLAN

This Executive Medical Reimbursement Plan (the "EMRP") is effective [DATE].

1. ELIGIBILITY

To be eligible for EMRP, an employee must be an officer of the [YOUR COMPANY NAME] (the"Company"). The employee must elect coverage for himself/herself and any eligible dependents underthe Company's [GROUP HEALTH PLAN NAME] Group Health Plan.

2. ENROLLMENT

Upon becoming eligible for the EMRP, an employee will automatically be enrolled in the plan providedhe/she is currently enrolled in the [GROUP HEALTH PLAN NAME] Group Health Plan.

3. COVERAGE

Coverage will be extended by the plan for any medical expense which would be a deductible medicalexpense under [FEDERAL/STATE/PROVINCIAL] Income Tax regulations. This can include expenses notreimbursed by the [GROUP HEALTH PLAN NAME] Group Health Plan due to deductibles, co-insurance,plan exclusions, eyeglasses, orthodontics, medically necessary additions and alterations to a home, or[SPECIFY]. These and other expenses would be covered by the EMRP if they qualify under applicable[IRS or YOUR COUNTRY REVENUE AGENCY] regulations.

4. BENEFITS

The EMRP does not require satisfaction of a deductible. Eligible medical expenses will be reimbursed at100%.

5. CLAIM FILING

Bills for medical expenses should be submitted to [CLAIMS ADMINISTRATOR] in the special MRP(Medical Reimbursement Plan) envelopes provided. The administrator will first pay benefits under the[GROUP HEALTH PLAN NAME] Group Health Plan. Reimbursement for expenses not fully covered (ornot covered at all) by the [GROUP HEALTH PLAN NAME] Group Health Plan will then be paid for theEMRP.

6. MAXIMUM ANNUAL BENEFIT

The maximum EMRP benefits payable during a calendar year for a covered employee and family is$[AMOUNT].

8/2/2019 Executive Medical Reimbursement Plan

2/2

Copyright Envision SBS. 2007. All rights reserved. Protected by the copyright laws of the United States & Canada and by international treaties. IT IS ILLEGALAND STRICTLY PROHIBITED TO DISTRIBUTE, PUBLISH, OFFER FOR SALE, LICENSE OR SUBLICENSE, GIVE OR DISCLOSE TO ANY OTHER PARTY,THIS PRODUCT IN HARD COPY OR DIGITAL FORM. ALL OFFENDERS WILL BE SUED IN A COURT OF LAW.

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7. TAXES

Unlike benefits received from the Group Health Plan (which are not taxable income) payments under theEMRP are regular income. They are subject to both Federal and [STATE/PROVINCE] income tax, and[FICA or YOUR COUNTRY INSURANCE CONTRIBUTION ACT] if the employee's pay falls below the[FICA or YOUR COUNTRY INSURANCE CONTRIBUTION ACT] salary limit.

8. ADDITIONAL REIMBURSEMENT

In March of each year while the EMRP remains in effect, the Company will make an additional payment toeach employee who received benefits under the plan during the previous year. The amount paid will be apercentage of the EMRP benefits, calculated to cover the taxes generated by such benefit payments.That percentage may be changed from time to time in order to reflect changes in applicable tax rates. Theadditional reimbursement is also taxable income, and will be included in the employee's [W-2 or YOURCOUNTRY WAGE AND TAX STATEMENT] for the year in which the additional reimbursement was paid.

9. TERMINATION OF COVERAGE

Coverage will terminate on the earliest of the following dates:

A. An employee terminates employment with [YOUR COMPANY NAME].

B. Coverage under the Company's Group Health Plan terminates, either due to voluntary action onthe part of the employee, or because the Company has cancelled the Group Health Plan.

C. At the end of an approved leave of absence, unless the employee returns to full-time employmentwith the Company.

D. The employee is no longer an officer of the Company.

E. The Company elects to discontinue the Executive Medical Reimbursement Plan.

The EMRP is a cash bonus plan, not insurance. It is not funded, nor does it come under provisions of the[FEDERAL EMPLOYEE RETIREMENT INCOME SECURITY ACT or YOUR COUNTRY EQUIVALENT].