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` c�� axis ;:' human resourceful° CONEXIS FEE SCHEDULE / SERVICE APPENDIX CLIENT: City of Santa Ana ALL FEES BILL TO: City of Santa Ana, Personnel Services/Employee Benefits This Fee Schedule / Service Appendix is incorporated into and made a part of the CONEXIS Services Agreement ("Agreement'). If there is a conflict between this Fee Schedule I Service Appendix and the Agreement, the Agreement controls. Client understands and acknowledges that CONEXIS is entitled to reimbursement of implementation costs and expenses ('Implementation Expenses") not otherwise passed on to Client if this Agreement or the Fee Schedule/Service Appendix is terminated by Client without show of cause within the Service Fees Guarantee Period of any Fee Schedule I Service Appendix. In the event CONEXIS is entitled to reimbursement of Implementation Expenses herein, Client agrees to pay the Implementation Fee to CONEXIS within thirty (30) days of the effective date of the termination date. Penalty is assessed per Fee Schedule / Service Appendix with an in effect Service Fee Guarantee Period. HOW TO COMPLETE THIS PAGE: This Fee Schedule must be signed by an authorized representative of the Bill To party. By signing this Fee Schedule, the Bill To party agrees to the fees outlined for the Standard Services. Optional Services may be selected by initialing in the space provided next to the chosen service(s). If an optional service is not selected in this manner, the service will not be provided. Fees for Flexible Spending Account Administration R72TS Plan Documentation and Setup Fee $150.00 Required R15T2 Monthly Administration Fee $4.25 Required R21 DK Section 125 Tests ($100 per set of two tests) Billed perparticipant per month. Includes participationin health FSA and/ordependent care _R21 DL Section 105 Test ($100 per test) $100.00 R21 DM Section 129 Tests ($100 per set of three tests) FSA: R13TO 2.5 -month Grace Period Extension Administration - $3.00 R20FR CONEXIS Elite Visa Benefit Card Included Required R20FO Reimbursement Check Fee Included Required Per reimbursement check issued by CONEXIS R73M8 Minimum Monthly Fee $60.00 Required If total monthly billable fees are less than this minimum amount, an adjustment will be applied to bring the total up to the minimum amount R76TR Annual Renewal Fee $100.00 Required R671_8 Run -out Fee Required Monthly fee billed during each month of the run-outperiod for each active participant with a remaining balance. Billed at the Monthly Administration Fee in place at the time of the run- out period. R65138 Enrollment Form Data Entry by CONEXIS $8.00 Per enrollment form processed by CONEXIS R21 L3 Discrimination Testing (all six tests listed below) $300.00 Initial testing included at plan inception. Each additional round of testing will incur fees. R21 DK Section 125 Tests ($100 per set of two tests) $100.00 _R21 DL Section 105 Test ($100 per test) $100.00 R21 DM Section 129 Tests ($100 per set of three tests) $100.00 R13TO 2.5 -month Grace Period Extension Administration - $3.00 $3.00 x number of participants on last day of plan year. Subject to $100.00 minimum fee. Fee is incurred each plan year that the extension is chosen by employer. PEPM Billing - Less Than 1000 lives RAS Fee Schedule/Service Appendix 1 V9.0-040111