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WASHINGTON TEAMSTERS WELFARE TRUST SUBSCRIPTION AGREEMENT COLLECTIVE BARGAINING AGREEMENT PROVIDING FOR PARTICIPATIONIN TRUST The Employer and Labor Organization below are parties to a Collective Bargaining Agreement providing for participation in the above Trust. An enforceable Collective Bargaining Agreement must exist as a condition precedent to participation in the Trust. Kittitas County Misdemeanant & Juvenile Probation Teamsters Local No. 760 Employer Name 205 W 5th Ste 107 Address Ellensburg WA 98926 City State Zip Code COLLECTIVE BARGAINING AGREEMENT The parties' Collective Bargaining Agreement is in effect from: Labor Organization (Union) Name 1211 W Lincoln Ave. Address Yakima WA 98902 City 1/1/2016 ❑ New Account © Renewal — Account No. 109$69 INFORMATION CONCERNING EMPLOYER'S BUSINESS Employer EfN (Tax 1D No.) Employer is:❑ Public Entity ❑ Corporation - State of State Zip Code to: 12/31/2018 Approximate No. of Covered Employees 8 ❑ Partnership ❑ Sole Proprietorship ❑ LLC If Partnership or Sole Proprietorship, provide name/s of the owner or partners: _ BENEFITPLANS) DESIGNATED IN COLLECTIVE BARGA INI,Y'G AGREEMENT The Collective Bargaining Agreement provides that contributions will be made to the Trust on belialfof all employees for whotn the Employer is required to contribute under the Trust Operating Guidelines for the purpose of providing such employees and their dependents with the following benefit plan(s): (The undersigned parties acknowledge the receipt of a copy of the Trust Operating Guidelines which by this reference are made a part hereof.) COVERAGE IN RARGALVIAV AGREE• HEjVT (For renewals, Usr Qu eoverages, nor just chai:ges) Monthly Rate Medical Plan ❑ A ^ B LIC 0z 5906.40 LifejAD&D A - S30,000 Employee/S3,000 Dependent ❑ B - $15,000 Employee/$ 1, 500 Dependent C - $5,000 Employee/S500 Dependent $ Weekly Time Loss ❑ E - $500 U A - S400 Lj Lj B - $300 U C-$200 L1 D-$100 S Disabili Waivers ❑ Additional 9 months Disability Waiver of Contributions - Medical only S Domestic Partners ❑ Domestic Partners - Medical S Dental Plan ❑ A L) B C S Domestic Partners ❑ Domestic Partners - Dental S Vision Plan ❑ EXT $ Domestic Partners Domestic Partners - vision S Will there be any coverage changes before the Collective Bargaining Agreement's expiration? ❑ Yes ❑n No. If yes, attach a Subscription Agreement for each change. EFFECTIVE DA TE OF COXTRIB UTIONS - A Subscription : tgreerrtew must be submitted in advance of the effective shale below. Contributions above are eJfeclive (rnonih, year) January20 16 based an employmew in the prior manth lar orufnl. Coverage is effective in the month following the monde in which the contributivns are due based on the Trust's eligibility lag month. For example, con trihutions cffeedve.4pril based on Alurch employment will pro%'ide coverage in Afely. EXPIR,17TON OF COL LECTIT VE, BARG.4INING .4GREEA ENT Upon expiration of the above -referenced Collective Bargaining Agreement, the Employer agrees to continue to contribute to the Trust in the same amount and manner as required in the Collective Bargaining Agreement until such time as the Employer and the Labor Organization either enter into a successor Collective Bargaining Agreement, which conforms to the Trust Operating Guidelines, or one party notifies the other in writing (with a copy to the Trust) of its intent to cancel such obligation five (5) days after receiving notice, whichever occurs first. The Trust reserves the right to immediately terminate participation in the Trust upon the failure to execute this or an, auiure Subscription Agreement or to comply with the Trust operating Guidelines as amended by the Tru. • ' from im - to t tete. For Employer For Union Title: Assn%�,(�'_ (, rlrl� r1, Date Title Secretary -Treasurer Date 11-17-16