March 1, 2@@

Dear Employee:

YOUR COMPANY, INC. has put into place a Premium Only Plan under Act 125 effective January 1,
20@@. What this means is that your contribution toward the premium for IBX and UCCI Plan will be
considered on a pretax basis. This will reduce your taxable compensation by the amount of your
contribution.

This works similarly to a 401(k) plan in that your W-2 form will show the amount paid toward this
insurance and it will deducted from your gross compensation for Federal Income Tax purposes.

These pretax dollars to purchase benefits may reduce your FICA taxes and your Social Security benefits
in the future. If you do not wish to participate in this Act 125 plan there is a declination form available in
the accounting office that you must sign.

By completing the Health And Dental Insurance application you have elected to participate in this plan.
As reiterated previously the contribution amounts are as follows:

SINGLE (NO DEPENDENT COVERAGE) ______ PER PAY OR _______ PER MONTH

PARENT WITH CHILD(REN) COVERAGE ______ PER PAY OR _______ PER MONTH

HUSBAND AND WIFE COVERAGE ______ PER PAY OR _______ PER MONTH

FAMILY PLAN COVERAGE ______ PER PAY OR _______ PER MONTH

Should you have any questions regarding this notice please feel free to discuss them with YOUR NAME

Sincerely,

YOUR NAME

Cooordinator