2017-157-E HR - Selerix Systems, Inc. for 2017 ACA Subscription Agreement

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DocuSign Envelope ID:97D49820-FEB8-4DCA-BA8C-7909CD9FA2F9 e. SELERIX's provision to SUBSCRIBER of the ACA services does not include any consulting services, Ilegal,or financial services.. 2) Fees for Basic Services a. IRS Forms Generation, IRS AIR Form Filing & Lookback Reporting Fee per Medical Eligible lEmployee Employee Employee Count Annual Fee Monthly Fee* Tiler* First 250 1 .-250 $1,500 minimum Next 750 250 1,000 $6_00 $0.50 Next 4,000 1„001-5,000 $5_00 $0.41 Any additional 5,001+ $4_00 $0_33 #- Employers with fewer than 250 medical eligible employees are subject to the minimum annual charge of$1,500. * Monthly Fee means fee per Medical Eligible Employee per month for each month in the calendar year. Each calendar quarter the total number of medical eligible employees is calculated and the appropriate fee Is billed for the quarter in.advance. New clients will be billed based on projected employee count. At year end,the counts will be reconciled based on actual quarterly eligible employee counts of records maintained in the system_ Fees are calculated on a step-down basis as the employee count increases. If the total medical eligible employee count is 1,200. then the first 1,000 medical eligible employees are charged$6.00/year and the 200 in excess of 1,000 are charged$5.00/year. The medical eligible annual fee for this illustration would be$7000, b. Implementation Support Employee Tier* Employee Count Implementation Fee First 1,000 Up to 1,000 $1,000 Next 4„000 5,000 $2,,000 Any additional 5„001+ $3,,000 10 Hours of Implementation Support are included.. Implementation hours in excess of the 10 hours Will be billed at the rate of$175 per hour. c. Multiple EIIN Filling Charge There is no additional charge for filing one DN.. Additional IRS ACA fillings will be charged $500 per DIN for the reporting year.. For example, if an employer has 3 ElINs,the total additional filling charge would be$"11,000.. d. Account Manager Support Services Account Manager support hours required in excess of 20 hours annually will be charged at the rate of$175 per hour_ e. Fee Guarantee Period The above-described fees will remain valid for a period of 24 months from the Commencement Date of this Agreement. Thereafter, the annual fee may be amended by SELERIX, subject to the SUBSCRIBER's acceptance.. f.. Pricing Terms (1) Reporting Period_ SUBSCRIBER acknowledges ACA's annual reporting requirements..The services provided to SUBSCRIBER under this Agreement are services that are of benefit to SUBSCRIBER for the calendar year reportable to the 2017 ACA SUBSCRIPTION AGREEMENT FOR NON-LICENSEES. PAGE 4