2016-541-E HR - Gallagher Benefit Services for consulting services

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DocuSign Envelope ID:7B0EAFC2-08FE-4D8D-8809-FC9B16F772B3 „,,, -" (11, Arthur-J. Gallagher& Co. BUSINESS WITHOUT BARRIERS- CLIENT COVERAGE ACKNOWLEDGMENT AND COMPENSATION DISCLOSURE STATEMENT FOR Orange County,North Carolina This form documents that Gallagher Benefit Services, Inc. (Gallagher) will apply its professional judgment to access those insurance companies it believes are best suited to insure the Client's risks. The final decision to choose any insurance company has been made by the Client in its sole and absolute discretion.The Client understands and agrees that Gallagher does not take risk,and that Gallagher does not guarantee the financial solvency or security of any insurance company. The Client is responsible for immediate payment of premiums for all insurance placed by Gallagher on Client's behalf.If any premium amounts are not paid in full when due,the applicable insurance company for the Client's risks may cancel any applicable policies in accordance with the terms of such policies. The following is the disclosure of fees and/or commissions to be paid to Gallagher as a result of its Broker of Record relationship to Client's Group Health and Welfare Plan and any relationships, or agreements Gallagher has with any insurance companies selected by Client as noted above. Gallagher, as Broker of Record,will receive the following initial and renewal sale commissions expressed as percentage of gross premium payments, or fees as agreed upon by Client: Orange County,North Carolina Commission'/' Line of Coverage Insurance Company E DateVe Supplemental Direct Fees3 Compensation Direct Fee GBS 07/01/2016 If commissions for the N/A below lines do not reach a minimum of$105,000,a consulting fee amount for the difference will be billed and paid on a monthly basis. Medical United Healthcare 07/01/2016 $2 PEPM/$0-$2 PEPY N/A Dental Delta Dental of NC 07/01/2016 0% N/A Vision Community Eye Care 07/01/2016 10% N/A Life AD&D/Supplemental MetLife 07/01/2016 10.12%!1.25% N/A Life Short Term Disability AUL 07/01/2016 20% N/A It should also be noted that: • Gallagher is not an affiliate of the insurer whose contract is recommended. This means the insurer whose contract is recommended does not directly or indirectly have the power to exercise a controlling influence over the management or policies of Gallagher. Gallagher's ability to recommend other insurance contracts is not limited by an agreement with the insurance company. • Gallagher is effecting the transaction for the Plan(s)in the ordinary course of Gallagher business.The transaction set forth is at least as favorable to the Plan(s)as an arm's length transaction with an unrelated party. ' Commissions include all commissions/fees paid to Gallagher that are attributable to a contract or policy between a plan and an insurance company,or insurance service.This includes indirect fees that are paid to Gallagher paid by a third party,and includes,among other things,the payment of"finders'fees"or other fees to Gallagher for a transaction or service involving the plan. z Gallagher companies may receive supplemental compensation referred to in a variety of terms and definitions,such as contingent commissions,additional commissions and supplemental commission. 3 Direct Fees include compensation to Gallagher paid for directly by the plan sponsor/Client. Gallagher Client Coverage Acknowledgment 05302014 ©2016 GALLAGHER BENEFIT SERVICES,INC. ARTHUR J.GALLAGHER&CO.I AJG.COM