18868 - Subscription Agreement - 01.17.17(1)

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WASHINGTON TEAMSTERS WELFARE TRUST SUBSCRIPTION AGREEMENT COLLECTIVE BARGAINING AGRI EMENTPROVIDING FOR PARTICIPALION INTRUST 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 Line Teamsters Local Union No. 760 Employer Name Labor Organization (Union) Name 205 W Fifth 1211 W Lincoln Ave. Address Ellensburg WA 98926 City State Zip Code COLLECTIVE BARGAINING AGREEMENT The parties' Collective Bargaining Agreement is in effect from: Address Yakima WA 98902 City January 1, 2017 State Zip Code to: December 31, 2021 ❑ New Account■❑ Renewal — Account No. 105071 Approximate No. of Covered Employees 30 INFORMATION CONCERNING EMPLOYER'S B USINESS Employer EIN (Tax ID No.) Employer is: 0 Public Entity ❑ Corporation - State of ❑ Partnership ❑ Sole Proprietorship ❑ LLC If Partnership or Sole Proprietorship, provide name/s of the owner or partners: BENEFIT PLA NQ DESIGNATED IN COLLECI'I VE BARGAINING AGREEMENT The Collective Bargaining Agreement provides that contributions will be made to the Trust on behalf of all employees for whom 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 BARGAINING AGREEMENT (For renewals, list all coverages, not just changes) Monthly Rate Medical Plan X A 0 B ❑ C ❑ Z $1367.40 ❑ Life/AD&D LK ❑ A - $30,000 Employee/$3,000 Dependent B - $15,000 Employee/$1,500 Dependent C - $5,000 Employee/$500 De pendent $440 Weekly Time Loss ❑ E - $500 ,A - $400 B - $300 C-$200 ❑ D-$100 $ Disability, Waivers ❑ Additional 9 months Disability Waiver of Contributions - Medical only $ Domestic Partners ❑ Domestic Partners — Medical $ Dental Plan Q A B ❑ C $130.50 Domestic Partners ❑ Domestic Partners — Dental $ Vision Plan 0 EXT $14.90 Domestic Partners Lj Domestic Partners — Vision $ Will there be any coverage changes before the Collective Bargaining Agreement's expiration? ❑ Yes 9 No. If yes, attach a Subscription Agreement for each change. EFFECTIVE DATE OF CONTRIBUTIONS - A Subscription Agreement must be submitted in advance of the effective date below. Contributions above are effective (month, year) January 20 17 based on employment in the prior month. Important: Capyrl IS a ective in the month following the month in which the contributions are due based on the Trust's eligibility lag month. For example, contributions effective April based on March employment will provide coverage in May. EXPIRATION OF COLLECTIVE BARGAINING AGREEMENT 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 any future Subscription Agreement or to comply with the Trust Operating Guidelines as amended by the Trustees from time to time. For Employer Title/Assn Date For Union y , 4& Title Secretary -Treasurer Date % ^3'11