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					                                        INSTRUCTIONS AND FORMS TO BE COMPLETED


KHI – Omnicare – ON-BOARDING PACKET (printing required)
    o   Employment Application – Complete and return. (5 pages)
    o   Non-Disclosure Agreement – Read, complete, and return. (4 pages)
    o   New Employee Information – Fully complete as we will create your Employee File from this document. (1 page)
    o   Trak-1 Consumer Rights Notice – A Summary of Your Rights under the Fair Credit Reporting Act. (2 pages)
    o   Trak-1 Applicant Authorization – Employment Screening:
            −    Disclosure and Authorization for Employer to Access Consumer Reports. (2 pages)
            −    Notice Regarding Background Investigation Pursuant to California Law. (1 page)
    o   Applicant Data Record – Completion of this form is Optional. (2 pages)
    o   Form I-9 – Employment Eligibility Verification – Please fill in Section 1 completely. Section 2 is to be filled out by a notary
        or employment representative. You will also need to provide the notary appropriate identifying documents. See the “List
        of acceptable documents” in the I-9 instruction guide. (5 pages)
    o   Notary or Employment Representative Instructions for I-9 – Print instructions and take them to a notary (usually
        located at your bank and provide services at no cost) or employment representative. (1 page)
    o   Form W-4 – Federal Employee Withholding – Fill out bottom 1/3rd of page for proper tax withholding. Top portion and
        second page worksheets are for your use only. (2 pages)
    o   Form MO W-4 – Missouri State Tax Form – Complete and return. (1 page)
    o   Direct Deposit – Global Cash Card Agreement Form – For electronic payment of your paycheck. While not mandatory,
        we strongly encourage direct deposit for the quickest and easiest way to receive your check. (1 page)

ELECTIVE PROGRAMS (printing optional)
        Global Cash Card Information – The Global Cash Card Paycard is an alternative to direct deposit and acts like a debit card.
        Your check will go on it and you may use it for your purchases or at the ATM. *Please note the fees associated with this
        card as detailed on the form. The card does take 2-4 weeks to receive and your check will be live mailed until you receive
        the card in the mail and activate it. (1 page)
        OptiMed Benefit Plan – Must complete if you would like to enroll in the Health Savings Plan. You must enroll within 30
        days of hire or wait until open enrollment at the end of the year. (12 pages)


Completed Packets
Please submit your Trak-1 Applicant Disclosure and Authorization for Employer to Access Consumer Reports form immediately.
Mail, fax, or email the remaining forms and documents prior to your first day of work so there is no delay in employment:

        KHI Solutions Inc.
        5875 Castle Creek Parkway, Suite 425
        Indianapolis, IN 46250
        ATTN: Human Resources – Outsourcing Department
        EMAIL: KHI_STAFFING_HR@KHISolutionsInc.com
        FAX: 866.650.5434
                                                 Employment Application
                                                                                                              PLEASE PRINT ALL
                                                                                                           INFORMATION REQUESTED
                                                                                                              EXCEPT SIGNATURE


                                               APPLICATION FOR EMPLOYMENT

PLEASE COMPLETE PAGES 1-5.                                                          DATE _________________________________

Name _______________________________________________________________________________________________
                          Last                         First                           Middle                            Maiden

Present address _______________________________________________________________________________________
                            Number                       Street              City        State      Zip

How long ____________________                                             Social Security No. _______ – _____ – _________

Telephone (     )                     Cellular Phone (         )____________________

E-Mail Address ____________________________________________________________

If under 18, please list age _____________________

                                                                              Days/hours available to work
Position applied for (1) ________________________                             No Pref: ___________       Thur:            ___________
and salary desired (2) ________________________                                  Mon: ___________          Fri:           ___________
(Be specific)                                                                    Tue: ___________          Sat:           ___________
                                                                                Wed: ___________          Sun:            ___________

How many hours can you work weekly? ________________________ Can you work nights? ________________________

Employment desired               FULL-TIME ONLY                 PART-TIME ONLY                   FULL- OR PART-TIME

When available for work? ______________

_____________________________________________________________________________________________________


                                                                  LOCATION             NUMBER OF YEARS
  TYPE OF SCHOOL            NAME OF SCHOOL                                                                              MAJOR & DEGREE
                                                      (Complete mailing address)         COMPLETED
High School

College

Bus. or Trade School

Professional School


HAVE YOU EVER BEEN CONVICTED OF A FELONY OR MISDEMEANOR?                                                  No                  Yes

(Exclude convictions for marijuana-related offenses more than two years old; convictions that have been sealed, expunged,
or legally eradicated, and misdemeanor convictions for which probation was completed and the case was dismissed.)

If yes, please briefly describe the nature of the crime(s), the date and place of conviction and the legal disposition of the case.
This company will not deny employment to any applicant solely because the person has been convicted of a crime. The
company however, may consider the nature, date and circumstances of the offense as well as whether the offense is relevant to
the duties of the position for which is being applied.
 ____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________



                                                                                                               Employment Application – Page 1 of 5
                                                                                                 PLEASE PRINT ALL
                                                                                              INFORMATION REQUESTED
                                                                                                 EXCEPT SIGNATURE




Do you have a reliable means of transportation to work? _______________________________________________________

                                                               Skills


                Yes                                               Yes            Word               Yes
Typing          No           _____ WPM                10-key      No             Processing         No        _____ WPM

Personal        Yes        PC                                    Other _____________________________________________
Computer        No         Mac                                   Skills _____________________________________________


Please list three references that are previous employers, coworkers, or supervisors.



Name

Position

Company

Address

Telephone (     )




Name

Position

Company

Address

Telephone (     )




Name

Position

Company

Address

Telephone (     )




                                                                                               Employment Application – Page 2 of 5
                                                                                                      PLEASE PRINT ALL
                                                                                                   INFORMATION REQUESTED
                                                                                                      EXCEPT SIGNATURE


                                                            MILITARY


HAVE YOU EVER BEEN IN THE ARMED FORCES?                            Yes      No

ARE YOU NOW A MEMBER OF THE NATIONAL GUARD?                                 Yes        No

Specialty ___________________________________ Date Entered _________________ Discharge Date _______________


Work Experience         Please list your work experience for the past five years beginning with your most recent job held.
                        If you were self-employed, describe the type of work performed. Attach additional sheets if necessary.


Name of employer                                                     Name of last           Employment dates       Pay or salary
                                                                      supervisor
Address
                                                                                        From                   Start

City, State, Zip Code                                                                   To                     Final


Phone number                                                     Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.




Name of employer                                                     Name of last           Employment dates       Pay or salary
                                                                      supervisor
Address
                                                                                        From                   Start

City, State, Zip Code                                                                   To                     Final


Phone number                                                     Your Last Job Title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.




                                                                                                    Employment Application – Page 3 of 5
                                                                                                  PLEASE PRINT ALL
                                                                                               INFORMATION REQUESTED
                                                                                                  EXCEPT SIGNATURE


Work Experience         Please list your work experience for the past five years beginning with your most recent job held.
                        If you were self-employed, describe the type of work performed. Attach additional sheets if necessary.


Name of employer                                                     Name of last      Employment dates         Pay or salary
                                                                      supervisor
Address
                                                                                       From                 Start

City, State, Zip Code                                                                  To                   Final


Phone number                                                     Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.




Name of employer                                                     Name of last      Employment dates         Pay or salary
                                                                      supervisor
Address
                                                                                       From                 Start

City, State, Zip Code                                                                  To                   Final


Phone number                                                     Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.




May we contact your present employer?            Yes      No

Did you complete this application yourself       Yes      No

If not, who did? ________________________________________________________________________________________




                                                                                                 Employment Application – Page 4 of 5
                              AGREEMENT (PLEASE READ CAREFULLY BEFORE SIGNING)

I certify that all the information on this application is accurate and complete to the best of my knowledge and understand that
misleading or false statements will constitute sufficient cause for refusal of hire or termination of my employment.

I agree to submit to drug and alcohol testing, if requested by KHI Solutions Inc. (KHI). I release KHI, and its employees, plus
other persons or companies, from any and all liability arising out of or related in any way to such testing.

I authorize KHI to investigate information concerning my education, employment experiences and all other aspects of my
background relevant to my proposed employment. I release KHI and its employees from all liability arising from such
investigation. I understand employment with KHI is contingent on successfully passing drug and background screening.

I acknowledge and agree that I will not submit a resume or job application, nor otherwise be considered for a position with a
client of KHI, through or by any entities competitive to KHI, for a period of twelve (12) months from KHI’s submittal to that
client. I will not discuss an employment or contractual relationship, or provide information about such relationship to any of
KHI’s competitors or clients, or solicit, entice, or promote placement or hire with any KHI competitors or client.

I have read and considered the above provisions, and accept these provisions as the terms and
conditions of my candidacy or future placement with KHI. I understand that there is no guarantee of
employment, and that should my submittal materialize into an employment relationship, that employment
would be at will.




                                                             Signed:

                                            _________________________________


                                                             Printed:

                                            _________________________________



                                                              Date:

                                            _________________________________




KHI is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to
race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity
for employment with KHI depends solely on your qualifications.




                                                                                                     Employment Application – Page 5 of 5
                                          NON-DISCLOSURE AGREEMENT

THIS AGREEMENT is entered into between _______________________________________________
(hereinafter "Employee"), and KHI Solutions, Inc. (hereinafter "Employer"), an Indiana Corporation, with its
principal place of business located at 5875 Castle Creek Parkway, Suite 425, Indianapolis, IN 46250.

    WHEREAS, Employer and its subsidiaries and affiliates, own and operate businesses which provide,
among other products and services, training, consulting and temporary and direct hire staffing; and;

     WHEREAS, Employee wants to aid and assist Employer in the functions of and services rendered by
these businesses; and

      WHEREAS, in consideration of the employment and/or continued employment of the Employee, the
mutual covenants and agreements contained herein, the sufficiency and adequacy of which Employee
hereby recognizes, and any other or further consideration which may be or has been provided to Employee
in conjunction with the execution of this Agreement; and

    WHEREAS, execution of this Agreement by Employee is an express condition of Employee's
employment and/or continued employment by Employer;

     THE PARTIES HEREBY AGREES AS FOLLOWS:

I.    Proprietary Information

     A.                 Employee hereby acknowledges the highly competitive nature of the business(es) in
                        which Employer is or will be engaged, and that Employer owns and will own and uses
                        and will use certain proprietary information (as defined below) in conjunction with its
                        business which provides it with competitive advantages. Employee acknowledges that
                        certain of said proprietary information, including proprietary information of Employer,
                        its subsidiaries or affiliates, has been and will be disclosed to Employee and/or will be
                        developed or partially developed by Employee.

     B.                  Employer states that it wishes to secure and protect the secrecy and confidentiality of
                        said proprietary information. Employee acknowledges that the secrecy and
                        confidentiality of said proprietary information must be secured and protected for his
                        or her own good as an employee as well as for the good of Employer and all other
                        employees of Employer.

     C.                 The parties further wish to provide for the ownership of, and other rights in,
                        proprietary information which Employee has developed or helped develop during his
                        or her employment to date by Employer, and which Employee may develop or help
                        develop during his or her future employment by Employer, in accordance with
                        Employer's long-standing policy with respect to the ownership of, and other rights in,
                        proprietary information and the secrecy and confidentiality thereof.

     D.                 For the purposes of this Agreement, "proprietary information" shall mean any and all
                        of the following matter and information: trade secrets; ideas, discoveries or
                        inventions; formulas, specifications, patterns, or techniques; computations, software
                        and computer programs, devices, processes, or operation methods; products or
          1   KHI SOLUTIONS, INC. Non-Disclosure Agreement - OMNICARE
                         equipment, or new product developments, plans or improvements; customer
                         information, lists or subscription lists; financial information or statements; sales or
                         marketing information, plans or strategies; personnel information or new personnel
                         acquisition plans; details of author or consultant contracts; pricing policies;
                         projections; business acquisition plans; and other similar matter and information
                         which Employer, its subsidiaries or affiliates, own and will own and use and will use,
                         and/or which is useful in those various companies' businesses. "Proprietary
                         information'' shall not include such matter and information to the extent that it is
                         publicly known or becomes known to the public without violation of the terms of this
                         or any other Agreement, or is generally utilized by other persons or entities engaged in
                         the same business or businesses as Employer. Any failure to mark or designate
                         proprietary information as "confidential" or "secret" shall not affect its status as
                         proprietary information subject to the terms of this Agreement.

      E.                 All proprietary information shall be the sole and exclusive property of Employer and
                         Employer shall have all rights therein when said proprietary information is: (a)
                         developed by Employee (alone, with fellow employees or with others) in whole or in
                         part on Employer time, with Employer's materials or facilities and/or at Employer's
                         expense, and/or (b) learned by Employee from Employer or from fellow employees. To
                         the extent that Employee has developed or helped develop proprietary information
                         during his or her employment with Employer to date, Employee hereby assigns and
                         transfers any and all rights he or she may have therein to Employer. To the extent that
                         Employee develops or helps develop proprietary information during his or her future
                         employment with Employer, said proprietary information shall become the sole and
                         exclusive property of Employer. Employee shall promptly disclose to Employer all
                         proprietary information he or she develops in whole or in part during his or her
                         employment by Employer, and, at Employer's request, shall do all things reasonably
                         necessary in Employer's opinion to give Employer all property and other rights in said
                         proprietary information and/or to maintain said rights. Employer need not pay
                         Employee any royalty, fee or other amount above and beyond Employee's normal
                         salary or wages for developing or helping to develop any proprietary information.

      F.                 During the term of Employee's employment by Employer and thereafter, Employee
                         shall keep all proprietary information strictly confidential, and shall not, directly or
                         indirectly, disclose or reveal it to any third parties or use or seek to use it for his or her
                         own financial benefit or for the financial benefit of any person or entity other than
                         Employer; provided, however, that Employee may use said proprietary information in
                         the course of properly performing duties assigned to him or her by Employer.

      G.                 All notes, data, reference materials, sketches, drawings, memoranda, records and
                         other similar material which mentions or in any way relates to proprietary information
                         or Employer's business shall belong exclusively to Employer and shall be used by
                         Employee solely in the course of properly performing duties assigned to him or her by
                         Employer. Upon Employer's request or upon termination of Employee's employment
                         with Employer, Employee shall promptly turn over to Employer all such material in his
                         or her possession, custody or control.


II.   Standards of Business Conduct

           2   KHI SOLUTIONS, INC. Non-Disclosure Agreement - OMNICARE
       A.              Conflict of Interest. The term "conflict of interest'' describes any circumstance that could
                       cast doubt on an employee's ability to act with total objectivity with regard to Employer's
                       interest. Employee will avoid any action or involvement which could in any way
                       compromise his or her actions on behalf of Employer. Activities which could raise a
                       question of conflict of interest include, but are not limited to, the following:

                  1.                To conduct business on behalf of Employer with a member of the employee's
                                    family or a business organization with which the employee or a member of
                                    his or her family has a significant association, without first obtaining a
                                    written non-objection from an officer of the Employer.

                  2.                To serve in an advisory, consultative, technical or managerial capacity for any
                                    non-affiliated business organization which does significant business with or is
                                    a competitor of Employer, without first advising his or her department head
                                    of such plans.

                  3.                To accept any remunerated position outside Employer involving time when
                                    Employee could reasonably be expected to be working for Employer (for
                                    example, during the normal business day), or which interferes with the
                                    proper performance of Employee's duties.

                  4.                To take advantage of any business opportunity which might be of interest to
                                    Employer.

       B.              Legal Compliance. Employee will strictly comply with all laws and regulations that are or
                       may be applicable to Employer's business. Under no circumstances shall Employee make
                       any unauthorized copy of computer software or of any other copyrighted product.

       C.              Use of Common Assets. Employee will use Employer's facilities, equipment, supplies and
                       name only for conducting Employer's business or for purposes properly authorized by
                       Employer's management.

       D.              Customer Standards. Employee will comply with all standards, policies and procedures
                       dictated by Employer’s customers.

III.   Term of Employment

       Nothing contained in this Agreement shall create a contract of employment for any term, and insofar
       as this Agreement is concerned Employee's employment by Employer is terminable by either party at
       will. This means that either Employer or Employee may terminate the employment relationship at
       any time and for any reason, with or without cause.

IV.     Enforcement of this Agreement

       A.              In the event that any provision hereof is held invalid or unenforceable by a court of
                       competent jurisdiction, the remaining provisions hereof shall nonetheless be
                       enforceable. Further, in the event that any provision hereof is held to be over-broad as
                       written by such a court, such provision shall be deemed amended to narrow its

            3   KHI SOLUTIONS, INC. Non-Disclosure Agreement - OMNICARE
                application to the extent necessary to make the provision enforceable according to
                applicable law and enforced as amended. In the event that any of Employee's obligations
                hereunder are held by such a court to be over-broad with respect to duration,
                geographical scope or subject matter, such obligation shall be deemed amended to the
                maximum duration, geographical scope and subject matter allowable according to
                applicable law and enforced as amended.

B.              This Agreement cannot be amended, altered, enlarged, supplemented, abridged or
                modified, nor can any provision hereof be waived, except by the mutual written consent
                of the parties. Failure of either party to enforce any provision of this Agreement shall not
                constitute or be construed as a waiver of such provision, nor of the right to enforce such
                provision.

C.              Because of the unique nature of the proprietary information defined above, Employee
                understands and agrees that Employer will suffer immediate and irreparable harm in the
                event that Employee breaches any of his or her obligations hereunder and that monetary
                damages will be inadequate to fully compensate Employer for such breach. Accordingly,
                Employee understands and agrees that Employer shall, in addition to any other remedies
                available at law or in equity, be entitled to injunctive relief to enforce the terms and
                conditions of this Agreement.

D.              Employee shall be subject to, and agrees to submit to, the jurisdiction of any Indiana
                court for the purpose of resolving any and all disputes or actions relating in any way to
                this Agreement. Employee may bring any action relating in any way to this Agreement
                only in Indiana. This Agreement shall be governed by and construed under the laws of the
                State of Indiana.

E.              The parties hereby consent to service of process on them in any action relating in any
                way to this Agreement by regular mail sent to their last known address.

F.              In the event there is any action between or involving the parties relating in any way to
                this Agreement, Employee shall be liable to Employer for Employer's attorneys' fees and
                costs incurred in connection with such action if Employer prevails on any issue.

                Signed:_________________________________________________________________

                Printed Name: _____________________ _____________________________________

                Date: _______________________________________________________ __________




     4   KHI SOLUTIONS, INC. Non-Disclosure Agreement - OMNICARE
                                                     KHI Solutions Inc.

                 New Employee Information
      New Hire                   Rehire
                   For Rehire: Previous name if any __________________________

                         Personal Information

Last Name:____________________First Name:_______________Middle: ___________

Street Address:___________________________________________________________

City:_________________________________________State:_____Zip:______________

Home Phone:_______________Cell Phone: _______________Other: _______________

E-Mail:_________________________________________________________________

Social Security Number:__________________________Birth Date:_________________

Marital Status:____________________Spouse’s Name: __________________________

Spouse’s Employer:______________________Spouse’s Work Phone:_______________

                      Employment Information
Job Title:_____________________________________Start Date:__________________

Work Location:_____________________________________Rate of Pay:____________

                  Emergency Contact Information
Last Name:__________________________First Name: __________________________

Street Address:___________________________________________________________

City:_________________________________________State:_____Zip:______________

Home Phone:_______________Cell Phone:______________Other:_________________

Relationship:_____________________________________________________________




                                                   New Employee Information – Page 1 of 1
                                               A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT
                                                                                   CONSUMER RIGHTS NOTICE

    Para informcaion en espanol, visite https://www.ftc.gov/credit o escribe a la FTC Consumer Response Center, Room 130 – 600
    Pennsylvania Ave NW, Washington DC 20580.

                               A SUMMARY OF YOUR RIGHTS UNDER the FAIR CREDIT REPORTING ACT

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer
reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as
agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your
major rights under the FCRA. For more information, including information about additional rights, go to www.ftc.gov/credit or
write to: Consumer Response Center, Room 130- A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C.
20580.

    •   You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of
        consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against
        you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.

    •   You have the right to know what is in your file. You may request and obtain all the information about you in the files of a
        consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include
        your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

             •   a person has taken adverse action against you because of information in your credit report;

             •   you are the victim of identity theft and place a fraud alert in your file;

             •   your file contains inaccurate information as a result of fraud;

             •   you are unemployed but expect to apply for employment within 60 days.

In addition, by September, 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each
nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.ftc.gov/credit for additional
information.

    •   You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on
        information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or
        distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you
        will receive credit score information for free from the mortgage lender.

    •   You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is
        incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute
        is frivolous. See www.ftc.gov/credit for an explanation of dispute procedures.

    •   Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate,
        incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer
        reporting agency may continue to report information it has verified as accurate.

    •   Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency
        may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

                   TRAK-1 TECHNOLOGY | 7131 Riverside Parkway | Tulsa, Oklahoma 74136 | Tel. 1 (800) 600 – 8999 | www.trak-1.com
                                         CH1.11718343.1 | Consumer Release: Employment or Volunteer

                                                          TRAK-1 TECHNOLOGY Fair Credit Reporting Act – Consumer Rights Notice – Page 1 of 2
    •    Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid
         need – usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies
         those with a valid need for access.

    •    You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out
         information about you to your employer, or a potential employer, without your written consent given to the employer.
         Written consent generally is not required in the trucking industry. For more information, go to www.ftc.gov/credit.

    •    You may limit “prescreened” offers of credit and insurance you get based on information in your credit report.
         Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose
         to remove your name and address from the lists on which these offers are based. You may opt- out with the nationwide
         credit bureaus at 1-800-392-7816.

    •    You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a
         furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

    •    Identity theft victims and active duty military personnel have additional rights. For more information, visit
         www.ftc.gov/credit.

States may enforce the FCRA and many states have their own consumer reporting laws. In some cases, you may have more rights
under state law. For more information, contact your state or local consumer protection agency or your state Attorney General.
Federal enforcers are:

                       TYPE OF BUSINESS                                                                    CONTACT
Consumer reporting agencies, creditors and others not listed                Federal Trade Commission: Consumer Response Center-FCRA
below.                                                                      Washington, DC 20580                      1-877-382-4357

National banks, federal branches/agencies of foreign banks                  Office of the Comptroller of the Currency Compliance
(word “National” or initials “N.A.” appear in or after bank’s               Management, Mail Stop 6-6 Washington, DC 20219
name)                                                                                                                       800-613-6743

Federal Reserve System member banks (except national banks,                 Federal Reserve Board: Division of Consumer & Community
and federal branches/agencies of foreign banks)                             Affairs Washington, DC 20551                  202-452-3693

Savings associations and federally chartered savings banks (word            Office of Thrift Supervision: Consumer Complaints, Washington,
“Federal” or initials “F.S.B.” appear in federal institution’s name)        DC 20552                                       800-842-6929

Federal credit unions (words “Federal Credit Union” appear in               National Credit Union Administration 1775 Duke Street
institution’s name)                                                         Alexandria, VA 22314                           703-519-4600

State-chartered banks that are not members of the Federal                   Federal Deposit Insurance Corporation: Consumer Response
Reserve System                                                              Center, 2345 Grand Avenue Ste 100 Kansas City, Missouri
                                                                            64108-2638                                  1-877-275-3342

Air, surface, or rail common carriers regulated by former Civil             Department of Transportation, Office of Financial Management
Aeronautics Board or Interstate Commerce Commission                         Washington, DC 20590                            202-366-1306

Activities subject to the Packers and Stockyards Act, 1921                  Department of Agriculture: Office of Deputy Administrator –
                                                                            GIPSA Washington, DC 20250                    202-720-7051




                    TRAK-1 TECHNOLOGY | 7131 Riverside Parkway | Tulsa, Oklahoma 74136 | Tel. 1 (800) 600 – 8999 | www.trak-1.com
                                          CH1.11718343.1 | Consumer Release: Employment or Volunteer

                                                           TRAK-1 TECHNOLOGY Fair Credit Reporting Act – Consumer Rights Notice – Page 2 of 2
                                                                                                           APPLICANT AUTHORIZATION -
                                                                                                              EMPLOYMENT SCREENING


                       DISCLOSURE AND AUTHORIZATION FOR EMPLOYER TO ACCESS CONSUMER REPORTS
           KHI Solutions Inc. | 5875 Castle Creek Parkway, Suite 425 | Indianapolis, IN 46250 | 866.926.2085

DISCLOSURE
By signing below, you acknowledge and understand that in connection with your application for employment with KHI Solutions
Inc.(KHI) (including any independent contract for services) or when deciding whether to modify or continue your ongoing
employment* (if hired), we may obtain a “consumer report” and/or an “investigative consumer report” on you from TRAK-1
TECHNOLOGY, a consumer reporting agency, or from any third party, in strict compliance with both state and federal law. A
consumer report is any communication of information by a consumer reporting agency bearing on your credit worthiness, credit
standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be
used for purposes of serving as a factor in establishing your current and/or continuing eligibility for employment purposes. An
investigative consumer report is obtained through personal interviews with individuals who may have knowledge of your character,
general reputation, personal characteristics, or mode of living. The consumer reports or investigative consumer reports may contain
public record information which may be requested or made on you including, but not limited to: consumer credit, criminal records,
civil cases in which you have been involved, driving history records, current motor vehicle insurance coverage, education records,
previous employment history, workers compensation claims history, social security traces, military records, professional licensure
records, eviction records, drug testing, government records, and others. You further understand that these reports may include
experience information along with reasons for termination of past employment. You also acknowledge and understand that
information from various federal, state, local and other agencies which contain information about your past activities will be
requested, and that a consumer report containing injury and illness records and medical information may be obtained only after a
tentative offer of employment has been made. You are hereby notified that you have the right to make a timely request for a copy
of the scope and nature of the above investigative background report and/or a complete copy of your consumer report contained in
KHI‘s files on you at the time of your request by providing proper identification and the payment of any legally permissible fees. You
are further notified that, prior to being denied employment based in whole or in part on information obtained in the consumer
report, you will be provided a copy of the report, the name, address and telephone number of the consumer reporting agency and a
description in writing of your rights under the Fair Credit Reporting Act. Correspondence to TRAK-1 TECHNOLOGY should be
forwarded to: Trak-1 Technology; Consumer Disputes; P.O. Box 52028; Tulsa, Oklahoma, 74152. 1 (800) 600 – 8999.

 CALIFORNIA APPLICANTS: California Civil Code section 1786.16(2) requires a separate disclosure and authorization to be signed
 by an applicant or current employee each time a background check is performed for employment purposes. This requirement
 does not apply in situations where the employer has a suspicion of wrongdoing or misconduct by a current employee.


 MAINE APPLICANTS: Pursuant to Maine state law, § 1317(2), Trak-1 Technology is required to reinvestigate any consumer dispute
 made by a consumer residing in the state of Maine within 21 calendar days of notification of the dispute by the consumer.

THE FAIR CREDIT REPORTING ACT GIVES YOU SPECIFIC RIGHTS IN DEALING WITH CONSUMER REPORTING AGENCIES. YOU WILL BE
GIVEN A SUMMARY OF THESE RIGHTS TOGETHER WITH THIS DOCUMENT.
AUTHORIZATION
By signing below, you hereby authorize, without reservation, TRAK-1 TECHNOLOGY or any third party contacted by this organization
to furnish the abovementioned and requested information. You further authorize ongoing procurement of the above-mentioned
information, reports and records at any time during your employment or contract or in the course of considering you for
employment. You also agree that a fax or photocopy of this authorization with your signature is accepted as having the same
authority as the original. You further authorize and request, without reservation, any present or former employer, school, police
department, financial institution, division of motor vehicles, consumer reporting agencies, or other persons or agencies having
knowledge about you to furnish KHI with any and all background information in their possession regarding you, so that your
employment qualifications may be evaluated and/or reassessed.




                   TRAK-1 TECHNOLOGY | 7131 Riverside Parkway | Tulsa, Oklahoma 74136 | Tel. 1 (800) 600 – 8999 | www.trak-1.com
                                         CH1.11718343.1 | Consumer Release: Employment or Volunteer

                                                             TRAK-1 TECHNOLOGY Applicant Authorization – Employment Screening – Page 1 of 3
ACKNOWLEDGEMENT OF RECEIPT OF SUMMARY OF RIGHTS
By signing below, I certify: (1) that I have read and fully understand this disclosure and authorization; (2) that all of the
information I am providing is true, complete, correct and accurate; and (3) that I have received the attached Summary of Your
Rights under the Fair Credit Reporting Act (15 U.S.C. §1681 et seq.).

The following is information required in order for KHI to obtain a complete consumer report:


FULL LEGAL NAME (First, Full Middle Name, Last Name)


STREET ADDRESS


CITY                                           STATE                                                       ZIP


SOCIAL SECURITY NUMBER                                                                                     DATE OF BIRTH *


DRIVER’S LICENSE NUMBER                                                                                    ISSUING STATE


OTHER OR FORMER NAMES (AKA, Maiden Names, Married Names, Surnames, Etc.)


HIGH SCHOOL NAME/ GED PROGRAM                                                                              DATE GRADUATED/ GED RECEIVED


CONSUMER’S SIGNATURE                                                                                       DATE

* This information will be used for background screening purposes only.


   Check this box if you are a Minnesota, Oklahoma, or California applicant, and you would like to receive a copy of your consumer
report, if one is obtained. For California applicants only: a copy of your report will be sent to you by the above-referenced employer
within three business days beginning on the date of receipt by the employer. For Minnesota applicants only: the consumer reporting
agency shall furnish a copy of your consumer report within twenty-four hours of providing it to the above-referenced employer. For
Oklahoma applicants only: the consumer reporting agency shall furnish a copy of your consumer report.


NOTICE TO CALIFORNIA APPLICANTS ONLY: Pursuant to § 1786.22 of the California Civil Code, you may view the file maintained on
you by Trak-1 Technology during normal business hours. You may also obtain a copy of this file, either in person or by mail, by
submitting proper identification and paying the costs of duplication services. You may also receive a summary of the file by
telephone upon production of adequate identification. Trak-1 is required to have trained personnel available to explain your file to
you and any coded information contained therein. You may appear in person alone, or with another person of your choice, provided
that this additional person furnishes proper identification.




                   TRAK-1 TECHNOLOGY | 7131 Riverside Parkway | Tulsa, Oklahoma 74136 | Tel. 1 (800) 600 – 8999 | www.trak-1.com
                                         CH1.11718343.1 | Consumer Release: Employment or Volunteer

                                                             TRAK-1 TECHNOLOGY Applicant Authorization – Employment Screening – Page 2 of 3
                                                                                                           APPLICANT AUTHORIZATION -
                                                                                                              EMPLOYMENT SCREENING

              NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW

KHI (the “Company”) intends to obtain information about you for employment purposes from an investigative consumer reporting
agency or consumer credit reporting agency. Thus, you can expect to be the subject of “investigative consumer reports” and
“consumer credit reports” obtained for employment purposes. Such reports may include information about your character, general
reputation, personal characteristics and mode of living. With respect to any investigative consumer report from an investigative
consumer reporting agency (“ICRA”), the Company may investigate the information contained in your employment application and
other background information about you, including but not limited to obtaining a criminal record report, verifying references, work
history, your social security number, your educational achievements, licensure, and certifications, your driving record, and other
information about you, and interviewing people who are knowledgeable about you. The results of this report may be used as a
factor in making employment decisions. The source of any investigative consumer report (as that term is defined under California
law) will be Trak-1 Technology; P.O. Box 52028; Tulsa, Oklahoma, 74152; 800-600-8999. The source of any credit report will be
Trak-1 Technology; P.O. Box 52028; Tulsa, Oklahoma, 74152; 800-600-8999. The Company agrees to provide you with a copy of an
investigative consumer report when required to do so under California law.

Under California Civil Code section 1786.22, you are entitled to find out from an ICRA what is in the ICRA’s file on you with proper
identification, as follows:

    •   In person, by visual inspection of your file during normal business hours and on reasonable notice. You also may request a
        copy of the information in person. The ICRA may not charge you more than the actual copying costs for providing you with
        a copy of your file.

    •   A summary of all information contained in the ICRA’s file on you that is required to be provided by the California Civil Code
        will be provided to you via telephone, if you have made a written request, with proper identification, for telephone
        disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to you.

    •   By requesting a copy be sent to a specified addressee by certified mail. ICRAs complying with requests for certified mailings
        shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the ICRAs.

“Proper Identification” includes documents such as a valid driver’s license, social security account number, military identification
card, and credit cards. Only if you cannot identify yourself with such information may the ICRA require additional information
concerning your employment and personal or family history in order to verify your identity.

The ICRA will provide trained personnel to explain any information furnished to you and will provide a written explanation of any
coded information contained in files maintained on you. This written explanation will be provided whenever a file is provided to you
for visual inspection.

You may be accompanied by one other person of your choosing, who must furnish reasonable identification. An ICRA may require
you to furnish a written statement granting permission to the ICRA to discuss your file in such person’s presence.




                   TRAK-1 TECHNOLOGY | 7131 Riverside Parkway | Tulsa, Oklahoma 74136 | Tel. 1 (800) 600 – 8999 | www.trak-1.com
                                         CH1.11718343.1 | Consumer Release: Employment or Volunteer

                                                             TRAK-1 TECHNOLOGY Applicant Authorization – Employment Screening – Page 3 of 3
                                                                                                       Optional

                                        Applicant Data Record


All qualified applicants are considered for employment, and employees are treated during employment
without regard to race, color, religion, sex, national origin, age, citizenship, disability, or Vietnam era
veteran status, "special disabled veteran" status or other eligible veteran status. Additionally, KHI
Solutions Inc. (KHI) provides reasonable accommodation to qualified individuals with disabilities.

To help KHI comply with applicable government regulations concerning equal employment opportunity and
affirmative action, it requests that you complete the Applicant Data Record. Submission of this
information is voluntary. You will not be subjected to any adverse treatment if you do not provide the
information requested. This data will be kept in a separate file from your Application for Employment.


Date:         /       /              Name:          ________________________________________


 Gender

             Female              Male


 Ethnicity

        Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or
        other Spanish culture or origin, regardless of race.


 Race

        White (not Hispanic or Latino): A person having origins in any of the original peoples of Europe,
        the Middle East or North Africa.

        Black or African American (not Hispanic or Latino): A person having origins in any of the black
        racial groups of Africa.

        Native Hawaiian or Other Pacific Islander (not Hispanic or Latino): A person having origins in
        any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands.

        Asian (not Hispanic or Latino): A person having origins in any of the original peoples of the Far
        East, Southeast Asia or the Indian subcontinent, e.g., Cambodia, China, India, Japan, Korea,
        Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.

        American Indian or Alaska Native (not Hispanic or Latino): A person having origins in any of
        the original peoples of North and South America (including Central America), and who maintains
        tribal affiliation or community attachment.

        Two or More Races (not Hispanic or Latino): A person who identifies with more than one of the
        above races, excluding those who identify themselves as Hispanic or Latino.




                                                                               Applicant Data Record – Page 1 of 2
                                                                                                           Optional
 Veteran Status

I wish to identify myself as a covered veteran.


       Disabled Veteran -- (1) A veteran of the U.S. military, ground, naval or air service who is entitled to
       compensation (or who but for the receipt of military retired pay would be entitled to compensation) under
       laws administered by the Secretary of Veterans Affairs, or (2) A person who was discharged or released
       from active duty because of a service-connected disability.

       Recently Separated Veteran -- Any veteran during the three-year period beginning on the date of such
       veteran's discharge or release from active duty in the U.S. military, ground, naval or air service.

       Armed Forces Service Medal Veteran -- Any veteran who, while serving on active duty in the U.S.
       military, ground, naval or air service, participated in a United States military operation for which an
       Armed Forces service medal was awarded pursuant to Executive Order 12985

       Other Protected Veteran -- A veteran who served on active duty in the U.S. military, ground, naval or
       air service during a war or in a campaign or expedition for which a campaign badge has been
       authorized, under the laws administered by the Department of Defense.


 Disability Status

       I wish to identify myself as an individual with a disability. "Individual with a disability" includes any
       person who has a physical or mental impairment which substantially limits one or more of such person's
       major life activities.



You are not required to provide the above information. If you do, efforts will be made to keep the
information confidential, except where disclosure is required by law or where disclosure is necessary in
order to provide a reasonable accommodation.




                                                                                   Applicant Data Record – Page 2 of 2
                     Notary or Employment Representative Instructions for I-9




Due to the location of KHI Solutions Inc. Human Resources Department, the services of a Notary Public
may be utilized to verify presentation of acceptable documents.



   •   The notary or employment representative is to complete section 2 of the I9

           o   The notary or employment representative is to view the employee’s identifying
               documents, listing one identifying document in “List A” or one identifying document in
               both “List B” and “List C.” Page 4 of the I-9 identifies Acceptable Documents.

           o   The notary is to sign under “Signature of Employer or Authorized Representative” and
               print name, title, and date.


       Contact Human Resources- Outsourcing Department for assistance with any questions:

               Toll Free: 1.877.256.6948 x6121




                                                Notary or Employment Representative Instructions for I-9 – Page 1 of 1
Form W-4 (2011)                                               Complete all worksheets that apply. However,
                                                              you may claim fewer (or zero) allowances. For
                                                                                                                                Form 1040-ES, Estimated Tax for Individuals.
                                                                                                                                Otherwise, you may owe additional tax. If you
                                                              regular wages, withholding must be based on                       have pension or annuity income, see Pub. 919 to
Purpose. Complete Form W-4 so that your                       allowances you claimed and may not be a flat                      find out if you should adjust your withholding on
employer can withhold the correct federal                     amount or percentage of wages.                                    Form W-4 or W-4P.
income tax from your pay. Consider completing a               Head of household. Generally, you may claim                       Two earners or multiple jobs. If you have a
new Form W-4 each year and when your                          head of household filing status on your tax return                working spouse or more than one job, figure the
personal or financial situation changes.                      only if you are unmarried and pay more than                       total number of allowances you are entitled to
Exemption from withholding. If you are exempt,                50% of the costs of keeping up a home for                         claim on all jobs using worksheets from only one
complete only lines 1, 2, 3, 4, and 7 and sign                yourself and your dependent(s) or other                           Form W-4. Your withholding usually will be most
the form to validate it. Your exemption for 2011              qualifying individuals. See Pub. 501, Exemptions,                 accurate when all allowances are claimed on the
expires February 16, 2012. See Pub. 505, Tax                  Standard Deduction, and Filing Information, for                   Form W-4 for the highest paying job and zero
Withholding and Estimated Tax.                                information.                                                      allowances are claimed on the others. See Pub.
                                                              Tax credits. You can take projected tax credits                   919 for details.
Note. If another person can claim you as a
dependent on his or her tax return, you cannot                into account in figuring your allowable number of                 Nonresident alien. If you are a nonresident alien,
claim exemption from withholding if your income               withholding allowances. Credits for child or                      see Notice 1392, Supplemental Form W-4
exceeds $950 and includes more than $300 of                   dependent care expenses and the child tax                         Instructions for Nonresident Aliens, before
unearned income (for example, interest and                    credit may be claimed using the Personal                          completing this form.
dividends).                                                   Allowances Worksheet below. See Pub. 919,                         Check your withholding. After your Form W-4
                                                              How Do I Adjust My Tax Withholding, for                           takes effect, use Pub. 919 to see how the
Basic instructions. If you are not exempt,
                                                              information on converting your other credits into                 amount you are having withheld compares to
complete the Personal Allowances Worksheet
                                                              withholding allowances.                                           your projected total tax for 2011. See Pub. 919,
below. The worksheets on page 2 further adjust
your withholding allowances based on itemized                 Nonwage income. If you have a large amount of                     especially if your earnings exceed $130,000
deductions, certain credits, adjustments to                   nonwage income, such as interest or dividends,                    (Single) or $180,000 (Married).
income, or two-earners/multiple jobs situations.              consider making estimated tax payments using
                                              Personal Allowances Worksheet (Keep for your records.)
A       Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . .                                                  A

B       Enter “1” if:    {   • You are single and have only one job; or
                             • You are married, have only one job, and your spouse does not work; or
                             • Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
                                                                                                                                                   . . .}       B

C       Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more
        than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . .                                           C
D       Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . .                                       D
E       Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . .                                   E
F       Enter “1” if you have at least $1,900 of child or dependent care expenses for which you plan to claim a credit                             . . .        F
        (Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
G       Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
        • If your total income will be less than $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if you have three or more eligible children.
        • If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter “1” for each eligible
          child plus “1” additional if you have six or more eligible children . . . . . . . . . . . . . . . . . .                                               G
H       Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) ▶ H



                             {
        For accuracy,          • If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
        complete all             and Adjustments Worksheet on page 2.
        worksheets             • If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed
        that apply.              $40,000 ($10,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.
                               • If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

                                      Cut here and give Form W-4 to your employer. Keep the top part for your records.


        W-4                               Employee's Withholding Allowance Certificate                                                                             OMB No. 1545-2159


                                                                                                                                                                      2011
Form
                                  ▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is
Department of the Treasury
Internal Revenue Service           subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
    1     Type or print your first name and middle initial.   Last name                                                                      2    Your social security number


          Home address (number and street or rural route)                                   3        Single          Married         Married, but withhold at higher Single rate.
                                                                                            Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
          City or town, state, and ZIP code                                                 4 If your last name differs from that shown on your social security card,
                                                                                                check here. You must call 1-800-772-1213 for a replacement card. ▶
    5     Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)           5
    6     Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . .                          6 $
    7     I claim exemption from withholding for 2011, and I certify that I meet both of the following conditions for exemption.
          • Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and
          • This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
          If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7
Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature
(This form is not valid unless you sign it.)      ▶                                                                                          Date ▶
    8     Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)            9 Office code (optional)    10    Employer identification number (EIN)


For Privacy Act and Paperwork Reduction Act Notice, see page 2.                                                   Cat. No. 10220Q                                       Form W-4 (2011)
Form W-4 (2011)                                                                                                                                                                   Page 2

                                                                Deductions and Adjustments Worksheet
 Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.

   1      Enter an estimate of your 2011 itemized deductions. These include qualifying home mortgage interest,
          charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and
          miscellaneous deductions . . . . . . . . . . . . . . . . . . . . . . . . .                                                                        1     $

   2      Enter:     {$11,600 if married filing jointly or qualifying widow(er)
                      $8,500 if head of household
                      $5,800 if single or married filing separately
                                                                                                       }
                                                                                   . . . . . . . . . . .                                                    2     $

   3      Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .                                                         3     $
   4      Enter an estimate of your 2011 adjustments to income and any additional standard deduction (see Pub. 919)                                         4     $
   5      Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to
          Withholding Allowances for 2011 Form W-4 Worksheet in Pub. 919.)         . . . . . . . . . . .                                                    5     $
  6       Enter an estimate of your 2011 nonwage income (such as dividends or interest) . . . . . . . .                                                     6     $
  7       Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .                                                         7     $
  8       Divide the amount on line 7 by $3,700 and enter the result here. Drop any fraction . . . . . . .                                                  8
  9       Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . .                                                         9
 10       Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,
          also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1                                     10

                            Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)
 Note. Use this worksheet only if the instructions under line H on page 1 direct you here.
  1    Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet)                                    1
  2    Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if
       you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more
       than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                                 2
   3      If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter
          “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . .                 3
 Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional
       withholding amount necessary to avoid a year-end tax bill.
   4      Enter the number from line 2 of this worksheet . . . . . . . . . .                      4
   5      Enter the number from line 1 of this worksheet . . . . . . . . . .                      5
   6      Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . .                                                                     6
   7      Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . .                                                 7     $
   8      Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . .                                         8     $
   9      Divide line 8 by the number of pay periods remaining in 2011. For example, divide by 26 if you are paid
          every two weeks and you complete this form in December 2010. Enter the result here and on Form W-4,
          line 6, page 1. This is the additional amount to be withheld from each paycheck . . . . . . . .                                                   9     $
                                         Table 1                                                                                        Table 2
         Married Filing Jointly                                  All Others                              Married Filing Jointly                             All Others
 If wages from LOWEST          Enter on          If wages from LOWEST          Enter on            If wages from HIGHEST     Enter on        If wages from HIGHEST       Enter on
 paying job are—               line 2 above      paying job are—               line 2 above        paying job are—           line 7 above    paying job are—             line 7 above
           $0 - $5,000 -                 0                 $0 - $8,000 -                    0             $0   - $65,000         $560               $0   - $35,000           $560
       5,001 - 12,000 -                  1             8,001 - 15,000 -                     1         65,001   - 125,000          930           35,001   - 90,000              930
     12,001 - 22,000 -                   2            15,001 - 25,000 -                     2        125,001   - 185,000        1,040           90,001   - 165,000           1,040
     22,001 - 25,000 -                   3            25,001 - 30,000 -                     3        185,001   - 335,000        1,220          165,001   - 370,000           1,220
     25,001 - 30,000 -                   4            30,001 - 40,000 -                     4        335,001   and over         1,300          370,001   and over            1,300
     30,001 - 40,000 -                   5            40,001 - 50,000 -                     5
     40,001 - 48,000 -                   6            50,001 - 65,000 -                     6
     48,001 - 55,000 -                   7            65,001 - 80,000 -                     7
     55,001 - 65,000 -                   8            80,001 - 95,000 -                     8
     65,001 - 72,000 -                   9            95,001 -120,000 -                     9
     72,001 - 85,000 -                 10            120,001 and over                     10
     85,001 - 97,000 -                 11
     97,001 -110,000 -                 12
    110,001 -120,000 -                 13
    120,001 -135,000 -                 14
   135,001 and over                    15
Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to               You are not required to provide the information requested on a form that is
carry out the Internal Revenue laws of the United States. Internal Revenue Code sections               subject to the Paperwork Reduction Act unless the form displays a valid OMB
3402(f)(2) and 6109 and their regulations require you to provide this information; your employer       control number. Books or records relating to a form or its instructions must be
uses it to determine your federal income tax withholding. Failure to provide a properly                retained as long as their contents may become material in the administration of
completed form will result in your being treated as a single person who claims no withholding          any Internal Revenue law. Generally, tax returns and return information are
allowances; providing fraudulent information may subject you to penalties. Routine uses of this        confidential, as required by Code section 6103.
information include giving it to the Department of Justice for civil and criminal litigation, to         The average time and expenses required to complete and file this form will vary
cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in            depending on individual circumstances. For estimated averages, see the
administering their tax laws; and to the Department of Health and Human Services for use in            instructions for your income tax return.
the National Directory of New Hires. We may also disclose this information to other countries
under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to          If you have suggestions for making this form simpler, we would be happy to hear
federal law enforcement and intelligence agencies to combat terrorism.                                 from you. See the instructions for your income tax return.
                 MISSOURI DEPARTMENT OF REVENUE
                 TAXATION DIVISION
                 P.O. BOX 3340                                                                                                                                            This certificate is for income tax withholding
                 JEFFERSON CITY, MO 65105-3340
                                                                                                                                                 MO W-4                   and child support enforcement purposes only.
                                                                                                                                                   (REV. 12-2010)         PLEASE TYPE OR PRINT.
                 FAX:(573) 526-8079
                 EMPLOYEE’S WITHHOLDING ALLOWANCE CERTIFICATE
 FULL NAME                                                                                                         SOCIAL SECURITY NUMBER                                                            SINGLE
                                                                                                                                                                             FILING
                                                                                                                                                                             STATUS                  MARRIED
                                                                                                                                                                                                     HEAD OF HOUSEHOLD
HOME ADDRESS (NUMBER AND STREET OR RURAL ROUTE)                                                                   CITY OR TOWN, STATE AND ZIP CODE



1. ALLOWANCE FOR YOURSELF: Enter 1 for yourself if your filing status
   is single, married, OR head of household. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. ALLOWANCE FOR YOUR SPOUSE: Does your spouse work?                                 Yes            No
   If YES, enter 0. If NO, enter 1 for your spouse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3. ALLOWANCE FOR DEPENDENTS: Enter the number of dependents you will claim on your tax return. Do not claim
   yourself or your spouse or dependents that your spouse has already claimed on his or her Form MO W-4. . . . . . . . . . . . . . . . . . . . 3
4. ADDITIONAL ALLOWANCES: You may claim additional allowances if you itemize your deductions
   or have other state tax deductions or credits that lower your tax. Enter the number of additional
   allowances you would like to claim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   4
5. TOTAL NUMBER OF ALLOWANCES YOU ARE CLAIMING: Add Lines 1 through 4 and enter total here. . . . . . . . . . . . . . . . . . . .                                                                5
6. ADDITIONAL WITHHOLDING: If you expect to have a balance due (as a result of interest income, dividends, income from a
   part-time job, etc.) on your tax return, you may request your employer to withhold an additional amount of tax from each
   pay period. To calculate the amount needed, divide the amount of the expected balance due by the number of pay periods
   in a year. Enter the additional amount to be withheld each pay period here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                             6    $
7. EXEMPT STATUS: If you had a right to a refund of ALL of your Missouri income tax withheld last year because you had NO
   tax liability and this year you expect a refund of ALL Missouri income tax withheld because you expect to have NO tax liability,
   write “EXEMPT” on Line 7. See information below. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                7
8. If you meet the conditions set forth under the Servicemember Civil Relief Act, as amended by the Military Spouses Residency
   Relief Act and have no Missouri tax liability, write "EXEMPT" on line 8. See information below. . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                       8
Under penalties of perjury, I certify that I am entitled to the number of withholding allowances claimed on this certificate, or I am entitled to claim exempt status.
EMPLOYEE’S SIGNATURE (Form is not valid unless you sign it.)                                                                                                             DATE
                                                                                                                                                                          ___ ___ / ___ ___ / ___ ___ ___ ___
EMPLOYER’S NAME                                                                                                                                                          FEDERAL EMPLOYER IDENTIFICATION NUMBER
                                                                                                                                                                          ___ ___ ___ ___ ___ ___ ___ ___ ___
EMPLOYER’S ADDRESS                                                                                                                                                       MISSOURI TAX IDENTIFICATION NUMBER
                                                                                                                                                                          ___ ___ ___ ___ ___ ___ ___ ___
             NOTICE TO EMPLOYER: Within 20 days of hiring a new employee, send a copy of Form MO W-4 to the: Missouri Department of Revenue, P.O. Box 3340,
            Jefferson City, MO 65105-3340 or fax to (573) 526-8079. For additional information regarding new hire reporting, please visit www.dss.mo.gov/cse/newhire.htm.

                                                           —EMPLOYEE INFORMATION—
                                        YOU DO NOT PAY MISSOURI INCOME TAX ON ALL OF THE INCOME YOU EARN!
                                                      Visit www.dor.mo.gov to try our online withholding calculator.
  Deductions and exemptions reduce the amount of your taxable income. Form MO W-4 is completed so you can have as much “take-home pay” as possible without an
  income tax liability due to the state of Missouri when you file your return. Deductions and exemptions reduce the amount of your taxable income. If your income is less
  than the total of your personal exemption plus your standard deduction, you should mark “EXEMPT” on Line 7 above. The following amounts of your annual Missouri
  adjusted gross income will not be taxed by the state of Missouri when you file your individual income tax return.

                        Single                                                           Married Filing Combined                                                              Head of Household
        $2,100 — personal exemption                                          $ 4,200 — personal exemption                                                                   $ 3,500 — personal exemption
        $5,800 — standard deduction                                          $11,600 — standard deduction                                                                   $ 8,500 — standard deduction
        $7,900 — Total                                                       $15,800 — Combined Total (For both spouses)                                                    $12,000 — Total
        + $1,200 for each dependent                                          + $1,200 for each dependent                                                                    + $1,200 for each dependent
        + up to $5,000 for federal tax                                       + up to $10,000 for federal tax                                                                + up to $5,000 for federal tax

                                                                                              Items to Remember:
  • If your filing status is married filing combined and your spouse works, do not claim an                         • If you itemize your deductions, instead of using the standard deduction, the amount not
    exemption on Form MO W-4 for your spouse.                                                                          taxed by Missouri may be a greater or lesser amount.
  • If you and your spouse have dependents, please be sure only one of you claim the                                • If you are claiming an "EXEMPT" status due to the Military Spouses Residency Relief Act you
    dependents on your Form MO W-4. If both spouses claim the dependents as an allowance                               must provide one of the following to your employer: Leave and Earnings Statement of the non-
    on Form MO W-4, it may cause you to owe additional Missouri income tax when you file                               resident military servicemember, Form W-2 issued to the nonresident military servicemember, a
    your return.                                                                                                       military identification card, or specific military orders received by the servicemember. You must
  • If you have more than one employer, you should claim a smaller number or no allowances                             also provide verification of residency such as a copy of your state income tax return filed in your
    on each Form MO W-4 filed with employers other than your principal employer so the                                 state of residence, a property tax receipt from the state of residence, a current drivers license,
    amount withheld will be closer to your amount of total tax.
                                                                                                                       vehicle registration or voter ID card.
MO 860-1598 (12-2010)
                                                                                                           KHI Solutions

                    Direct Deposit - Global Cash Card Agreement Form
                                                          Direct Deposit
                                               Direct Deposit Account Information

First Name:                                  Middle:                                  Last Name:

           Start Direct Deposit                         Stop Direct Deposit                            Change Direct Deposit
           Enroll in Global Cash Card                   Stop Global Cash Card

           Bank Name:                                 Account Type                            I wish to deposit (check one)
                                           * requires voided check or bank letter *

                                            Checking                                          Remainder of Net Pay
 ________________________                                                                     _________ % of Net
                                             Savings                                          Specific Dollar Amount $_________

                                            Checking                                          Remainder of Net Pay
 ________________________                                                                     _________ % of Net
                                             Savings                                          Specific Dollar Amount $_________

                                             Direct Deposit Authorization Signature
I hereby authorize my employer to initiate automatic deposits to my account at the financial institution named below. I also
authorize employer to make withdrawals from this account in the event that a credit entry is made in error. Further, I agree
not to hold employer responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me
or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account.
This agreement will remain in effect until employer receives a written notice of cancellation from me or my financial
institution, or until I submit a new direct deposit form to the Payroll Department.

Authorized Signature (Primary):                                                                Date:

Authorized Signature (Joint):                                                        Date:
           (If worker does not have authority to authorize deposits into Joint Account)
Please Note: A voided check or bank letter with account and routing numbers must be attached and returned along with this form.
             Deposit slips and bank account statements are not accepted.

                                                        Global Cash Card
                                             Global Cash Card Account Information
Print Legibly and ONLY complete if enrolling for a Cash Card

First Name:                                  Middle Initial:                          Last Name:

Street Address:                                                                       City:

State:                                      Zip Code:                             Social Security Number:              -        -

Home Telephone: (           )          -                         Date of Birth (MM/DD/YYYY):                   /           /

Cell Number (Optional): (          )           -           Email Address (Optional):
         **For text messaging confirmations/balances**                                                      **For email notifications**

Employee Signature:                                                                            Date:


The USA PATRIOT ACT is a Federal law that requires all financial institutions to obtain, verify, and record information that
identifies each person who opens an account. You will be asked to provide your name, address, date of birth, and other
information that will allow us to identify you. You may also be asked to provide documentation as proof of identification.

                                                                    Direct Deposit –Global Cash Card – Agreement Form – Page 1 of 1
                                                                       Global Cash Card Paycard

                                                                       … a great alternative to a
                                                                       checking or savings account!
                                                                       Customer Service 888.220.4477
Why Choose a Global Cash Card Paycard:
     24x7 access to funds                                              On time pay no matter what – pay is deposited onto the
     No waiting in line to cash your paycheck                          paycard on pay day
     Safe and secure – no need to carry cash, funds are FDIC           Ability to make internet purchases and pay bills online
     insured                                                           Earn Cash Rewards from over 750 great merchants
     Easy to make purchases at millions of merchants worldwide         Easy to Use!

Additional Benefits of a Global Cash Card Paycard:
 •      No monthly or annual fee                                   •     FREE first transaction per pay period
 •      FREE signature transactions                                •     FREE withdrawal of your money “to the
 •      FREE texting messaging and email alerts                          Penny” at a bank teller withdrawal
 •      FREE enrollment in Cash Rewards Program                    •     Over 37,000 surcharge free ATM networks
 •      FREE cards for family members                              •     No more check cashing fees
 •      No more lost or stolen checks                              •     FREE cash back at a point-of-sale
 •      FREE access to balance online or on phone                  •     Make card to card transfers
 •      FREE online statements                                     •     Online or telephone bill payment

Cardholder Fees – Paycard Program:
     Point of Sale
                      Signature Purchase:                 Free                             Signature Purchase:                       Free
                      PIN Purchase:                       $0.50                            PIN Purchase:                             $1.75
         INSIDE                                                          OUTSIDE
                      Signature Decline:                  $0.80                            Signature Decline:                        $1.50
      UNITED STATES                                                    UNITED STATES
                      PIN Decline:                        $0.45                            PIN Decline:                              $1.25
                      Return:                             $0.80                            Return:                                   $1.50

     ATM
                      Withdrawal(Surcharge Free/Allpoint): $1.75
         INSIDE                                                          OUTSIDE           Withdrawal:                               $3.50
                      Withdrawal (Out of Network):         $1.75
      UNITED STATES                                                    UNITED STATES       Other Transactions:                       $3.25
                      Other Transactions:                  $1.00

     Bill Pay                                                      Load Card
     Cardholder Direct to Merchant:                       Free     Direct Deposit:                                                   Free
     Online:                                              $0.99    MoneyGram* (Cash Only – U.S. Only)                                $5.95
     Telephone:                                           $0.99    Western Union* (Cash Only – U.S. Only)                            $4.45
                                                                                                                         *Fee Charged by Vendor.

     Money Transfer Worldwide (Card to Card)                       Account Fees
      $1         -    $100:                               $2.00    First Transaction per Pay Period:                                 Free
      $101       -    $250:                               $3.00    Periodic Statement (Mailed–If Requested):                         $1.50
                                                                   Transfer to/from Checking Account (ACH):                          $1.00
      $251       -    $500:                               $4.00
                                                                        *Free if First Transaction
       5
      $501       -    $750:                               $5.00    Global Cash Card Convenience Check:                               $1.50
      $751       -    $1000:                              $6.00         *Free if First Transaction
       1
      $1001      -    $1500:                              $7.00    Cash Advance (Bank Teller):                                       2%
      $1501      -    $2500:                              $8.00           *Free if First Transaction
                                                                   Inactivity Fee / Monthly:                                            $3.00
                                                                            *Loads are Activity (After Ninety (90) Days of Inactivity)
                                                                   Negative Balance Fee ATM Card:                                      $5.00
                                                                   Negative Balance Fee Debit MasterCard® / Visa®:                     $15.00

                                                                                                        Global Cash Card – Flyer – Page 1 of 1
OptiMed Benefits
KHI Solutions Inc.
Rate Chart Effective January 1, 2009

Coverage Includes:
Medical, Dental, Vision                                Employee          Employee +One              Family


Deducted from each check weekly                             $27.05                   $49.82            $72.21

As per OptiMed’s policy, benefits will become effective the first day of the month following start date.


Enrollment Requirements:
     ·   You must work at least 15 hours a week
     ·   Enrollment must be within 30 days of start date
     ·   Open enrollment is every December


If you decide to enroll in OptiMed please complete information and return.

OptiMed cards typically take 3-4 weeks to arrive in the mail. If you need to use your coverage before you
receive your card, please call OptiMed and they can help you with this.

OptiMed #: 1-800-482-8770
Policy #: LM-108
  OptiMed     •   No Health Questions Asked
              •   No Deductible
 Enrollment   •   No Coinsurance
    Kit       •
              •
                  No Co-pays on the Medical
                  No Pre-existing Condition
Dba           •
                  Clause
                  Benefits Paid Directly to the
                  Provider
              •   National Medical PPO Network
              •   Patient Advocacy
              •   Catastrophic Care Concierge
                  Service Assistance




                                    V1.01
                How Does OptiMed Medical Work?
                                         It’s Simple...
1. Find a Provider: Locates a participating network provider.
   Call OptiMed Customer Service at: 1-800-482-8770

2. Schedule an Appointment: Set up an appointment and see your doctor.

3. Benefit Amounts: OptiMed pays based on a fixed schedule of benefits. If the plan design states that
   you are entitled to a $60 office visit, the benefit you are entitled to is $60 even if you choose an out of
   network provider. OptiMed does not reduce the benefit amount.

4. Assignment of Benefits: OptiMed also allows an assignment of benefits. You should have to pay
   nothing up front. OptiMed does not have any deductibles or coinsurance, and prescriptions are subject to
   co-pays.

5. Payment: The provider should bill OptiMed directly. If the provider wishes you to pay up front have them
   call OptiMed customer service while you are at the provider’s office. If you elect to pay up front you can
   easily file a claim with OptiMed.

6. Network: If you chose an in network provider, you are entitled to a discount. This means that you are
   able to save out of pocket expenses. OptiMed discounts the bill and sends the provider the benefit
   payment along with an explanation of benefits. You also receive an explanation of benefits. Should there
   be a balance due, the provider then bills you for the difference. If you choose an out of network provider,
   you are still entitled to your benefit, but not a discount.



Example: Figures below are for illustrative purposes only. Actual Provider bills will vary.

             In-Network:                                                    Out of Network:

   Physician office visit bill:           $100                 Physician office visit bill:            $100

   Sample discount at 20%:               -$ 20                 No discount:                           -$ 00

   Benefit payment                       -$ 60                 Benefit payment                       -$ 60

   Member Out of Pocket                   $ 20                 Member Out of Pocket                   $ 40
                                  Discount Dental Care Program*
As a member of the CMC Total-Care Plan, you may take advantage of savings offered by an industry leader in
dental care. Careington International Corporation is one of the most recognized professional dental networks in
the nation and boasts a provider network of over 62,000 participating dentists.

•    Average annual savings of $1,200 per
     family on dental work
                                                                         SAMPLE SAVINGS CHART
•    Over 62,000 providers nationwide                  Code Procedure
                                                                                                       Plan         Retail         %
                                                                                                       Cost         Cost         Savings
•    Save 20% to 50% on most dental
     procedures including routine oral                  D0120    Periodic Oral Evaluation                $23           $49          53%
     exams, unlimited cleanings, and major
     work such as dentures, root canals, and            D0274    Bitewings-Four Films                    $29           $63          54%
     crowns
                                                        D1110    Prophylaxis-Adult (light                $45           $91          51%
•     Orthodontics included for both children                    Cleaning)
     and adults at a 20% savings                        D1120    Prophylaxis-Child                       $32           $67          52%

•     Cosmetic dentistry such as bonding and            D2160    Amalgam-Three Surface,                  $95          $210          55%
     veneers also included                                       Primary or Permanent

•    All specialties included-Endodontics,              D2750    Crown-Porcelain Fused to               $577         $1,070         46%
     Oral Surgery, Orthodontics, Pediatric                       High Noble Metal
     Dentistry, Periodontics, and                       D3330    Root Canal-Molar (Excluding            $558         $1,000         44%
     Prosthodontics– a 20% reduction on                          Final Restoration)
     normal fees where available
                                                        D4341    Periodontal Scaling and Root           $119          $248          52%
•    All dentist must meet highly selective                      Planing
     credentialing standards based on                                                                    $74          $167
                                                        D7140    Extraction-Erupted Tooth or                                        56%
     education, background, license standing                     Exposed Root
     and other requirements
                                                        D8080    Comprehensive Orthodontic              20%          $5,581         20%
•    Members may visit any participating                         Treatment of the Adolescent          Discount
     dentist on the plan and change providers                    Dentition
     at any time                                        This chart reflects a sample savings and actual retail pricing will vary by location.


These fees represent the CI-5 fee schedule. Normal cost is based on the 80th percentile of the National Dental
Advisory Service Comprehensive Fee Report for 2008. Prices subject to change.


                                    How To Access Your Discounts
                     ACCESS YOUR DISCOUNTS IN THREE EASY STEPS
               To locate a participating provider, call OptiMed Customer Service toll free at 1-800-482-8770 or visit
Step 1:        our website at www.careington.com to access the online provider search.




                Step 2:         You must show your membership card at the time of visit to receive your discount.




Step 3:        You are responsible for the total bill, less the applicable savings, at the time services are rendered.


Members pay 100% of the discounted price.
                                            *(Note: This is not an insurance benefit)
                                   Discount Vision Care Program*
Save 20% to 60% off the retail price on eyewear with your EyeMed Vision Care Discount Program.
Members are eligible for discounts on exams, glasses and contact lenses at more than 40,000 providers
nationwide, including participating Optometrists, Ophthalmologists, Opticians and leading optical
retailers, Sears Optical®, Target Optical® and most Pearl Vision® locations.


                                 PROGRAM DESCRIPTION
                         Vision Care Service                                               Member Discount
Exam:
Exam with Dilation as Necessary                                                         $5 off comprehensive exam
                                                                                         $10 off contact lens exam
Complete Pair Eyeglass Purchase Discounts:
*Frames, lenses and lens options purchased in same transaction
Frames:
Any available frames at provider location                                                 35% off the retail price
Standard Plastic Lenses:
  Single Vision                                                                                     $50
  Bifocal                                                                                           $70
  Trifocal                                                                                         $105
Lens Options:
  UV Coating                                                                                        $15
  Standard Scratch Resistant Coating                                                                $15
  Tint (Solid and Gradient)                                                                         $15
  Standard Polycarbonate                                                                            $40
  Standard Anti-Reflective Coating                                                                  $45
  Standard Progressive (Add-on to Bifocal)                                                          $65
  Other Add-Ons and Services                                                              20% off the retail price
Contact Lenses (Discount applies to materials only)
  Conventional                                                                            15% off the retail price
Laser Vision Correction:
  LASIK or PRK from U.S. Laser Network                                                   15% off the retail price or
                                                                                        5% off the promotional price

*Frames, lenses, and lens options discounts apply only when purchasing a complete pair of eyeglasses. If purchased separately,
members receive 20% off retail price.


Members pay 100% of the discounted price.
                                            *(Note: This is not an insurance benefit)
                                                 SAMPLE SAVINGS CHART
   Vision Care Service                        Retail Price                         Member Cost     Savings
Eye Exam                                             $50                                 $45          $5
Single Vision Lenses                                 $70                                 $50         $20
Frames: Example                                     $120                                 $78         $42
Lenses:
                                                     $20                                 $15         $15
Scratch Resistant Coating

*This chart reflects a sample savings and actual retail pricing will vary by location.


                                                  Value Added Services
Laser Vision Correction:
EyeMed and LCA-Vision have arranged to provide this program to all EyeMed members through one of the
largest laser networks available, the U.S. Laser Network. Members are entitled to 15% off the retail price or 5%
off the promotional price of LASIK or PRK procedures, whichever is the greater discount from a provider in the
US Laser Network. Simply call 1-800-5LASER6 to begin the process.

Replacement Contact Lenses by Mail:
EyeMed members may order replacement contact lenses at competitive prices via the Internet and have them
mailed directly to your home. Simply visit www.eyemedvisioncare.com for more information and a link to the
ordering site. This service is for replacement contact lenses only, and your EyeMed discount does not apply. Your
initial pair of contact lenses must still be purchased from your eye care provider to ensure proper fit and follow-up
care.



                                        How To Access Your Discounts

                        ACCESS YOUR DISCOUNTS IN THREE EASY STEPS


                 To locate a participating EyeMed provider, call OptiMed Customer Service toll free at 1-800-482-8770
Step 1:          or visit our website at www.eyemedvisioncare.com to access the online provider search.




                                   Schedule an appointment. When making an appointment tell the provider you are an
                 Step 2:           EyeMed member and provide your name, name of your organization or plan and your
                                   member number.




Step 3:          When you arrive, identify yourself as an EyeMed member and present your membership card.



                                               (Note: This is not an insurance benefit)
                                                                                 OptiMed
                                                                        Value Care Plus Custom Plan
            AVAILABLE OPTIMED BENEFIT OPTIONS                                                                                                          Benefit
            (All medical benefit maximums shown are per person)                                                                                       Amounts
            Calendar Year Overall Maximum Medical Benefit                                                                                               $100,000

            Outpatient Physicians Office Visit Benefit - $360 calendar year maximum                                                                   $60 per visit

            Emergency Room Benefit for Sickness - Included in office visit maximum                                                                    $60 per visit

            Wellness Care Benefit - $150 calendar year maximum                                                                                        $50 per visit

            Outpatient X-Ray & Lab - $300 calendar year maximum                                                                                       $30 per day

            Emergency Room Benefit for Accidents
                                                                                                                                                     $500 per visit
            (For treatment in an emergency room if performed within 72 hours of the accident)
            Inpatient Surgical Schedule-$2,000 calendar year maximum - See surgical schedule                                                             $2,000

            •     Outpatient Surgical Schedule- 50% of inpatient                                                                                         $1,000

            •     Anesthesiology - Inpatient and Outpatient                                                                                             20% of
                                                                                                                                                 surgical benefit paid

            Hospital Indemnity Benefit (for sickness or accidents) - Requires 24 hour stay                                                           $500 per day

            •     Intensive Care - 30 day calendar year maximum
                                                                                                                                                     $500 per day
                  (paid in addition to Hospital Indemnity Benefit)

            •     Substance Abuse - 30 day calendar year maximum                                                                                     $500 per day

            •     Skilled Nursing - for stays in a Skilled Nursing Facility after a 3+ day hospital stay                                             $250 per day
                  60 days maximum per stay

            •     Mental Illness - $5,000/year maximum & $30,000/lifetime maximum                                                                    $500 per day

            Employee Term Life Insurance/AD&D (Employee Only)                                                                                      $10,000/$10,000

            Dependent Life - Term Life Insurance Only
                                                                                                                                                        $5,000
            •     Spouse
                                                                                                                                                         $2,500
            •     Children 6 months to 19 (25 if full time student)
                                                                                                                                                          $250
            •     Infants 14 days to 6 months

            Outpatient Prescription Drug
            $10 generic co-pay/$15 oral contraceptives co-pay/$50 brand co-pay                                                                    $10 generic co-pay
            Prescription drug formulary applies. - Drugs not on the formulary receive discounts only.                                             $50 brand co-pay
            (Limitations/exclusions apply)

            •     Employee Only (calendar year maximum)                                                                                                  $2,500
            •     Employee + 1 (calendar year maximum)                                                                                                   $4,000
            •     Family (calendar year maximum)                                                                                                         $5,000

                                                                       PPO Medical Network: PHCS
           This is not a contract of insurance. Above Indemnity and Outpatient Prescription Drug plan benefits provided through Fidelity Security Life Insurance
           Company. This is a brief summary of a group limited medical indemnity insurance plan designed to assist you in the process of comparing several health
           insurance options. This plan is not major medical insurance and is NOT designed to replace, provide, or modify major medical insurance. Some provisions,
           benefits, and exclusions or limitations listed herein may vary by state.


                  Additional Included OptiMed Programs - These are not insurance benefits

           -Advance Earned Income Tax Credit                -National Dental
           -Catastrophic Care Assistance Services™          -National Vision Network
           -National Medical PPO                            -24 Hour Nurse Line
           -National Lab Program
           * Dental and Vision Discount Networks are not available for members residing in the following
             states: Nevada, Montana, Vermont, and Illinois.

           *The OptiMed Plan is a limited medical plan which is packaged with certain non-insured benefits, including discount drug card and PPO discounts.

Disclosures: Administered by United Group Programs, Inc. Prescription Drug, Term life, AD&D and limited medical benefits underwritten by Fidelity Security Life Insurance Company,
Kansas City, MO 64111 Policy Form Nos. M-6004/M-6005; M-9031/M-9022.
Certain states require a minimum of 51+ eligible employees. Before any presentation of a proposal, please check with your OptiMed sales representative to be certain that the program being
proposed is appropriate for the state intended. This is not an offer of sale. No offering of this material should be given without the expressed approval of OptiMed, and any offering will be
based upon state availability, underwriting guidelines, agent guide, and minimum group size and participation requirements being met. The OptiMed program is not available in all states,
including Washington. Please check with your OptiMed Group Sales Representative to confirm that OptiMed is available in the state or states in which you may have an interest in offering
OptiMed.
                                                       FRAUD WARNING NOTICE


For Residents of All States   Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an
                              application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
(except the following):


Arkansas                      Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
                              false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
                              prison.


Colorado                      It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for
                              the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial
                              of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides
                              false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or
                              attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance
                              proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

District of Columbia          Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the
                              insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance
                              benefits if false information materially related to a claim was provided by the Applicant.


Florida                       Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an
                              application containing any false, incomplete, or misleading information is guilty of a felony in the third degree.



Kentucky                      Any person who knowingly and with intent to defraud any insurance company or other person files an application for
                              insurance containing any materially false information or conceals, for the purpose of misleading, information
                              concerning any fact material thereto commits a fraudulent insurance act, which is a crime.


Louisiana                     Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
                              false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
                              prison.


Maine/Tennessee               It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the
                              purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.



Nebraska                      Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an
                              application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.



New Jersey                    Any person who includes any false or misleading information on an application for an insurance policy is subject to
                              criminal and civil penalties.



New Mexico                    Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
                              false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal
                              penalties.


Pennsylvania                  Any person who, knowingly and with intent to defraud any insurance company or other person, files an application for
                              insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading,
                              information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects
                              such person to criminal and civil penalties.




   A-01021
                                                                                      EXCLUSIONS

                                                                          Limited Medical Indemnity
                                                                   (See Compliance for state specific exclusions)

            Notwithstanding any provision in the Policy to the contrary, the Policy does not provide any benefits for the following charges, services or supplies:
             1) suicide or any attempt of suicide, while sane or insane (while sane in Colorado or Missouri);
             2) any intentionally self-inflicted Injury or Sickness or any attempt thereat (while sane in Colorado or Missouri);
             3) participation in a riot, insurrection, rebellion, civil commotion, civil disobedience, or unlawful assembly. For purposes of this exclusion,
                “participation” means to take an active part in common with others; “riot” means any use or threat to use force or violence or disturbance by
                three or more persons without authority of law. This does not include a loss, that occurs while acting in a lawful manner within the scope of
                authority;
             4) committing, attempting to commit, or taking part in a felony, battery, assault, or engaging in an illegal occupation;
             5) participation in a contest of speed in power driven vehicles, parachuting, parasailing, bungee jumping, scuba diving, stunt driving, rock climbing,
                flying ultra-light aircraft, skydiving, hang gliding or any hazardous sports activity for exhibition purposes;
             6) flying as a pilot, crew member, or passenger in any aircraft, except as a fare-paying passenger in any regularly scheduled commercial aircraft
                flying between established airports on a regularly scheduled route;
             7) any Accident occurring while the Insured Person is intoxicated (where the blood alcohol content meets the legal presumption of intoxication
                under the law of the state where the Accident took place);
             8) declared or undeclared war or acts thereof;
             9) accidental bodily Injury occurring while serving on full-time active duty in any Armed Forces of any country or international authority (any
                  premium paid will be returned by the Company prorated for any period of active duty);
            10) Accident or Sickness arising out of or in the course of any occupation for compensation, wage or profit or Benefits that the Insured Person is
                entitled to under any Workers’ Compensation Law, Occupational Disease Law or similar law, whether or not application for such Benefits have
                been made;
            11) unless specifically provided for in the Policy, charges for the treatment of:
                  a) Mental or Nervous Disorders;
                  b) alcoholism;
                  c) the voluntary taking of any poison or inhalation of gas, or voluntary taking of any drug, sedative or narcotic, unless prescribed by a
                      Physician and taken according to the prescribed dosage; or
                  d) substance abuse;
            12) charges for the treatment of:
                  a) codependency;
                  b) social, occupational or religious maladjustment;
                  c) compulsive gambling; or
                  d) chronic marital or family problems when not related to the primary focus of treatment which must be a diagnosable mental disorder;
            13) unless specifically provided for in the Policy, rest care or rehabilitative care and treatment;
            14) cosmetic surgery or care or treatment solely for cosmetic purposes or complications from such surgery, care or treatment. This includes but is not
                limited to: reconstructive surgery and prosthetic devices, unless due to an Accident and performed within one year from the Accident to repair a
                congenital or abnormal defect of a newborn child, while covered under the Policy;
            15) unless specifically provided for in the Policy, immunization shots and routine examinations such as: health exams, periodic check-ups, pre-
                marital exams, and routine physicals, unless they are necessary for the diagnosis and treatment of a Sickness;
            16) routine newborn care such as Hospital and Physician services during Hospital Confinement immediately following birth. Payment for routine
                Physician’s services will be limited to one routine Inpatient examination of the well newborn child performed by a Physician other than the
                Physician who delivered the baby or administered anesthesia during delivery;
            17) voluntary abortion, except with respect to the insured or covered spouse:
                  a) where such person’s life would be endangered if the fetus were carried to term; or
                  b) where medical complications have arisen from an abortion;
            18) the reversal of tubal ligation and vasectomies;
            19) charges for treatment of male or female infertility; artificial insemination, in vitro or in vivo fertilization, including any related testing,
                medications or Physician’s services;
            20) dependent child maternity;
            21) sex changes;
            22) unless specifically provided for in the Policy, treatment of obesity, weight reduction or dietetic control; except morbid obesity or disease etiology;
            23) unless specifically provided for in the Policy, charges for Outpatient food, food supplements or vitamins;
            24) unless specifically provided for in the Policy, charges for services in the nature of educational or vocational testing or training;
            25) charges related to smoking cessation;
            26) Pre-Existing Conditions, except as described in the Schedule of Benefits
            27) unless specifically provided for in the Policy, air, water or ground ambulance service;




Disclosures:
Certain states require a minimum of 51+ eligible employees. Before any presentation of a proposal, please check with your OptiMed sales representative to be certain that the program being
proposed is appropriate for the state intended. This is not an offer of sale. No offering of this material should be given without the expressed approval of OptiMed, and any offering will be
based upon state availability, underwriting guidelines, agent guide, and minimum group size and participation requirements being met. The OptiMed program is not available in all states,
including Washington Please check with your OptiMed Group Sales Representative to confirm that OptiMed is available in the state or states in which you may have an interest in offering
OptiMed.
                                                                             EXCLUSIONS (Continued)

            28) unless specifically provided for in the Policy, charges for treatment or services for temporomandibular joint dysfunction or TMJ pain syndrome,
                orofacial, or myofacial syndrome whether medical or dental in scope;
            29) with regard to any Outpatient benefit, visits made, examinations given, or x-rays or laboratory tests performed as an inpatient while Confined to
                a Hospital;
            30) unless specifically provided for in the Policy, prescription drugs;
            31) unless specifically provided for in the Policy, routine eye examinations, refractions, eyeglasses, or their fitting;
            32) unless specifically provided for in the Policy, any procedure intended to enhance an Insured Person’s quality of vision that is not essential to the
                treatment of a Sickness or Injury;
            33) unless specifically provided for in the Policy, hearing aids or their fitting;
            34) unless specifically provided for in the Policy, dental examinations, dental care or oral surgery other than expenses resulting from accidental
                Injury;
            35) experimental or investigational treatments or surgery;
            36) unless specifically provided for in the Policy, diagnostic and surgical procedures, including but not limited to, diagnostic laboratory and
                pathology procedures, diagnostic radiology, nuclear medicine and ultra sound procedures;
            37) charges for stand-by surgeons, pediatricians, anesthesiologists, anesthetists, or other doctors as defined by the plan, or stand-by supplies,
                equipment, rooms, or any other services, supplies or treatment not actually used in the care or treatment of an Accident or Sickness;
            38) charges made by, durable equipment recommended by, or drugs dispensed by; a physician, surgeon, nurse or other doctor who:
                   a) normally lives with the Insured Person;
                   b) is a member of the Insured Person’s family; or
                   c) is the Insured Person’s plan sponsor;
            39) charges for services provided outside the scope of the license of the institution or practitioner rendering service;
            40) any charge for which there is no legal obligation to pay; no charge is made; or in the absence of coverage, no charge would be made;
            41) charges incurred prior to the Insured Person’s Effective Date of coverage or after termination of coverage;
            42) charges for care or services furnished by any agency or program funded by federal, state or local government. This does not apply to Medicaid or
                where prohibited by law;
            43) charges which are not Medically Necessary for treatment of an Accident or Sickness;
            44) charges for services which are not related to and consistent with the treatment of any Accident or Sickness of the Insured Person;
            45) charges for medical care, services or supplies which are not furnished or prescribed by a Physician;
            46) charges for care, treatment, services or supplies that are not approved or accepted for the treatment of an Injury, Accident or Sickness by any of
                    the following:
                  a) The American Medical Association;
                  b) The U.S. Surgeon General;
                  c) The U.S. Department of Public Health; or
                  d) The National Institute of Health;
            47) charges in excess of the policy maximums as shown in the Schedule of Benefits; or
            48) any charge for a service or supply not specifically covered in the Schedule of Benefits.




            Coverage will continue as long as premiums are paid and the Group Master Policy remains in force. If you, as the
            Employer, currently sponsor health insurance coverage other than comprehensive major medical, you may not be
            eligible for OptiMed. Please contact your OptiMed group representative regarding availability.




Disclosures:
Certain states require a minimum of 51+ eligible employees. Before any presentation of a proposal, please check with your OptiMed sales representative to be certain that the program being
proposed is appropriate for the state intended. This is not an offer of sale. No offering of this material should be given without the expressed approval of OptiMed, and any offering will be
based upon state availability, underwriting guidelines, agent guide, and minimum group size and participation requirements being met. The OptiMed program is not available in all states,
including Washington Please check with your OptiMed Group Sales Representative to confirm that OptiMed is available in the state or states in which you may have an interest in offering
OptiMed.
                                                                    Term Life and AD&D Rider Exclusions

            Suicide while sane or insane is not covered under the Term Life Insurance Benefit for two years (one year in Colorado, Missouri or North Dakota)
            from the Insured Person’s Effective Date. In such event, the Company will only pay a benefit equal to the premium paid.

            No benefit will be payable for any Accidental Death or Dismemberment Loss caused by or contributed to by:

             1) Sickness, bodily or mental health, or diagnostic medical or surgical treatment;
             2) infection, except pyogenic infections resulting from an accidental bodily Injury or resulting from the accidental ingestion of a contaminated
                   substance;
             3) attempted suicide or intentional self-inflicted Injury or Sickness while sane or insane (while sane in Colorado or Missouri);
             4) declared or undeclared war or acts thereof;
             5) military service for any country or organization, including service with military forces as a civilian whose duties do not include combat; war or
                 any act of war whether declared or undeclared. Upon notice to the Company of entering the armed forces, the Company will return to the
                 Insured, pro-rata any premium paid, less any benefits paid, for any period during which the insured is in such service;
             6) participation in a riot or insurrection. “Participation” means taking an active part in common with others. “Riot” means any use or threat to use
                 force or violence by three or more persons without authority of law;
             7) Insured’s commission or attempted commission of a felony, assault or illegal action;
             8) voluntary taking of any poison, drug, sedative or narcotic or inhalation of any kind of gas unless prescribed by a Physician and taken according
                 to the prescribed dosage; or
             9) legal intoxication where the blood alcohol content of the Insured exceeds the legal limit of the state in which the accident took place;
            10) an on the job Injury that is covered by Workers’ Compensation; or
            11) participation in any non-occupational activity in which the Insured purposely exposes themselves to an increase accidental bodily Injury. These
                 activities include but are not limited to:
                  a. belaying and repelling rock climbing;
                  b. flying ultra-light aircraft;
                  c. hang-gliding, skydiving, scuba diving, para-sailing;
                  d. motorized vehicle stunt driving, racing, jumping drag racing and demolition;
                  e. bungee jumping;
                  f. any hazardous activity for exhibition purposes; or
                  g. flying as a pilot, crew member, or passenger in any aircraft, except as a fare-paying passenger in any regularly scheduled commercial
                     aircraft flying between established airports on a regularly scheduled route.

                                                 Outpatient Prescription Drug Policy Exclusions and Limitations

            Outpatient Prescription Drug benefits are not payable for the following items except as set forth in the rider:

             1) all over-the counter products and medications unless shown under the definition of Prescription Drug. This includes, but is not limited to,
                 electrolyte replacement, infant formulas, miscellaneous nutritional supplements and all other over-the-counter products and medications;
             2) blood glucose meters and insulin injecting devices;
             3) Depo-Provera, levonorgestral, condoms, contraceptive sponges, spermicides, sexual dysfunction drugs;
             4) biologicals (including allergy tests), blood products, growth hormones, hemophiliac factors, MS injectables, immunizations, all other injectables
                 unless shown under the definition of Prescription Drug;
             5) Aerochamber, Aerochamber with Mask, Peak Flow Meter, all other medical supplies and durable medical equipment unless shown under the
                 definition of Prescription Drug;
             6) liquid nutritional supplement, pediatric Legend Drug vitamins, prenatal Legend Drug vitamins, prescribed versions of Vitamins A, D, K, B12,
                 Folic Acid and Niacin – used in treatment versus as a dietary supplement, all other Legend Drug vitamins and nutritional supplements;
             7) anorexiants; Any cosmetic drugs including, but not limited to, Renova, skin pigmentation preps, Any drugs or products used for the treatment of
                 baldness, Topical dental fluorides;
             8) refills in excess of that specified by the prescribing physician, or refills dispensed after one year from the original date of prescription;
             9) all newly marketed pharmaceuticals or currently marketed pharmaceuticals with a new FDA approved indication for a period of one year from
                 such FDA approval for its intended indication;
            10) any drug labeled “Caution – limited by Federal Law for Investigational Use” or experimental drugs;
            11) any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment;
            12) drugs needed due to conditions caused, directly or indirectly, by an Insured Person taking part in a riot or other civil disorder, or the Insured
                 Person taking part in the commission of a felony;
            13) drugs needed due to conditions caused, directly or indirectly, by declared or undeclared war or an act of war; or drugs dispensed to an Insured
                 Person while on active duty in any armed forces;
            14) any expenses related to the administration of any drug;
            15) needles or syringes unless shown under the definition of Prescription Drug;
            16) drugs or medicines taken while in or administered by a hospital or any other health care facility or office;
            17) Drugs covered under Workers’ Compensation, Medicare, Medicaid or other governmental programs;
            18) Drugs, medicines or products which are not Medically Necessary;
            19) Brand Name Prescription Drugs (unless specifically provided for in the policy);
            20) Diaphragms, Erectile dysfunction Legend Drugs, unless specifically listed in the definition of Prescription Drug, Infertility Legend Drugs;
            21) Epi-Pen, Epi-Pen Jr., Ana-Kit, Ana-Guard, Glucagon-auto injection, Imitrex-auto injection;
            22) Smoking deterrents, Legend or over-the-counter.

            Limitation: Retail-the lesser of a 30-day supply or specified unit doses. Mail order not available.

Disclosures:
Certain states require a minimum of 51+ eligible employees. Before any presentation of a proposal, please check with your OptiMed sales representative to be certain that the program being
proposed is appropriate for the state intended. This is not an offer of sale. No offering of this material should be given without the expressed approval of OptiMed, and any offering will be
based upon state availability, underwriting guidelines, agent guide, and minimum group size and participation requirements being met. The OptiMed program is not available in all state,
including Washington. Please check with your OptiMed Group Sales Representative to confirm that OptiMed is available in the state or states in which you may have an interest in offering
OptiMed.
                                                                              Guidesoft, Inc                                                     Please Select One

                                                                         dba KHI Solutions Inc.                                                  Addition

 4 Terry Drive, Suite 1, Newtown, PA 18940                                   Enrollment Form                                                     Change
 Phone: (800) 482-8770 Fax: (215) 968-6301                                                                                                       Termination


                                 OptiMed Health Plans Limited Medical Indemnity Coverage Employee Enrollment Form

Information (Please print in ink)            Policy Number: LM-108

Plan Selected:                                                                                                                             Value Care Plus Custom

Name: (Last)                   (First)              (Middle Initial)                             Social Security Number:            Home Telephone Number:
                                                                                                          -       -                 (       )
Home Address: (Street)                    (City)                   (State)     (Zip Code)                                Best Time for Company to Call:
                                                                                                                         (Home)                 (Work)
Billing Address: (Street)                 (City)                   (State)     (Zip Code)                                Place of Birth:                  Date of Birth:
(If different)                                                                                                                                                 /        /
Status:            Male                  Single            Divorced           Age:       Fax Number:                                Email Address:
                    Female               Married           Widowed                       (       )

Group:    Guidesoft, Inc dba Knowledge Services                                                       Work Telephone Number:                    Date of Hire:
                                                                                                      (       )                                       /            /

Beneficiary: (Last)            (First)              (Middle Initial)                                  Relationship:


Dependent Information (Complete only for Dependents to be covered under this plan)

                    Dependents Name:
                                                                       Sex:          Date of Birth:           Social Security Number:               Full-Time Student:
                     (First and Last)
Spouse:                                                                              /       /

Child:                                                                               /       /                                                       Yes           No

Child:                                                                               /       /                                                       Yes           No

Child:                                                                               /       /                                                       Yes           No

Child:                                                                               /       /                                                       Yes           No

(Attach a separate sheet for additional children)


Requested Effective Date (check one):
          I request an effective date of __________________________ (must be the 1st of the month). I understand I cannot change this date.
          None, since I am declining coverage.

     Declination of Coverage:
This section must be completed if you are declining coverage for yourself and/or your Dependents. I have been given the opportunity to apply for group
insurance provided through Fidelity Security Life Insurance Company. The reason I am not applying for coverage is: _______________________________.
I understand the Effective Date of Coverage for myself and/or my Dependents may not be available until the next Open Enrollment Period should I desire to
apply at a later date unless I am not included as a Late Entrant as defined in the Policy, or unless I apply for coverage during the Annual Open Enrollment
Period.

Coverage (check one):               Employee Only
                                    Employee Plus 1 Dependent
                                    Family

                                                            FIDELITY SECURITY LIFE INSURANCE COMPANY
                                                                   Kansas City, Missouri 64111

I have reviewed this form and represent the information provided is true and complete.
I acknowledge and agree that the insurance product presented and applied for is not a major medical policy; the insurance benefits included in the plan are
limited; I am not an independent contractor or self-employed worker; my dependents (for whom I am applying for coverage) and I are not covered under any
other limited medical or major medical plan and that if at any time I or my dependents obtain other limited medical or major medical coverage, then my
dependents and/or I are no longer eligible under this plan.

I hereby represent that I have reviewed the fraud warning notice (if applicable) included with this application for my state of residence.

Dated at _________________________________________ on the ____________________________ day of _________________________, 20________.
                      (City and State)                                (Day)                              (Month)             (Year)

Signature (Parent or Guardian if Under 18)                                                                        Date

A-01021

				
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