1. Participation. The employer or employee organization (as described in sections 3(4) or 3(5) of ERISA, respectively) named in the Master Application
(“Participating Employer”) hereby adopts as a participating employer the ChoiceBuilder Welfare Benefit Insurance Trust (the “Trust”), as set forth in the
instrument(s) creating such Trust (the “Trust Agreement”). Such action shall be effective on the date shown below with respect to the sub-trust first named
below that the Participating Employer is eligible to adopt in accordance with the terms of the Trust.
(a) Master Trust
(b) Industry Sub-Trust
(c) Single Employer Sub-Trust
(4 of 5)
ADDITIONAL TERMS & CONDITIONS TO THE CHOICEBUILDER WELFARE BENEFIT INSURANCE TRUST MASTER
2. Ratification of Trust Agreement. Participating Employer hereby ratifies, accepts and agrees to be bound by all of the provisions of the Trust Agreement as
amended from time to time, a copy of which has been made available to it.
Acceptance of Trustee and Administrator
. Participating Employer hereby accepts the trustee and administrator named in the Trust Agreement as the
trustee and administrator of the Trust (the “Trustee and Administrator”) with all of the rights, powers and responsibilities set forth in the Trust Agreement
and agrees to be bound by and ratifies the actions heretofore or hereafter taken by the Trustee and Administrator in accordance with the terms of the Trust
4. Trustee’s Action. Participating Employer acknowledges and agrees that its request to participate in the Trust pursuant to this Request for Participation
shall not be effective until accepted by the Trustee in accordance with the terms of the Trust Agreement. Trustee hereby represents that, before this Request
for Participation was entered into, all information described in Paragraph 9 hereof was provided to the fiduciary of the Participating Employer with the
authority to enter the Participating Employer into the Trust (the
“Responsible Plan Fiduciary”
5. Benefits Subject to Provisions of Insurance Policies. Participating Employer agrees to be bound by the terms and conditions of the Trust Policies (as
defined in the Trust Agreement) under which its employees become covered and agrees to pay all premiums required by the provisions of the Trust Policies
for the coverages it purchases. Participating Employer understands that the insurance coverages it elects to purchase hereunder may terminate or lapse if
such premiums are not paid when required by the provisions of the Trust Policies.
Assignment to Applicable Trust
. Participating Employer agrees that the Trustee may assign or cause it to be assigned to any sub-trust under the Trust for
which the Participating Employer is eligible at the time of this request. The Participating Employer acknowledges that it has indicated its proper Standard
Industry Classification Code below to facilitate such assignment and that the Trustee may assign or cause it to be assigned to a different sub-trust under the
Trust for which it becomes eligible in the future, should the Trustee deem this advisable.
7. Establishment of Plan; Designation of Claims Administrator. Participating Employer agrees that, by adopting this Trust, it is establishing an employee
welfare benefit plan (the
) in accordance with the Employee Retirement Security Act of 1974, as amended (
) to provide its eligible employees
with the insurance benefits provided by the Policies. Participating Employer further agrees that it will communicate the terms of the Plan to all eligible
employees, and will maintain such Plan in full force and effect so long as any employee remains eligible for such insurance benefits. Participating Employer
hereby designates, in accordance with Section 503 of ERISA, the Carrier issuing a Policy as the named fiduciary under the Plan with complete and
discretionary authority to review all denied claims for insurance benefits under such Policy and to construe disputed or doubtful Policy terms with respect to
such insurance benefits and that such Carrier shall be deemed to properly exercise such authority unless it abuses its discretion by acting arbitrarily and
8. Limitations on Participating Employer’s Rights and Responsibilities under the Trust. Participating Employer’s sole responsibility under the Trust is to adopt
it as set forth in this Request for Participation. Upon acceptance of its adoption by the Trustee, Participating Employer shall have no further rights, duties or
responsibilities under the Trust, except to the extent otherwise provided therein.
9. Disclosure of Fees and Conflicts of Interest. Notwithstanding anything herein to the contrary, this Request for Participation shall not become effective until
the Trustee, to the best of its knowledge, provides or causes to be provided to the Responsible Plan Fiduciary the following disclosures or such other
disclosures as may be required by ERISA:
(continued on next page)
(a) All services to be provided by the Trustee or any of its affiliates (collectively, the “Service Providers”) pursuant to the Trust Agreement, this Request
for Participation and any other agreements or arrangements related to the provision of benefits by the Trust or Policies (collectively, the “Service
), the compensation or fees (including, gifts, awards, or trips received, or to be received, from any source on account of the Service
Provider’s position with the Plan) for such services, and the manner of receipt of such compensation. Such disclosure shall provide a description of the
manner of receipt of compensation or fees and shall state whether the Service Providers will bill the Participating Employer, deduct fees directly from the
Plan accounts, or reflect a charge against the Plan investment. Such disclosure will also describe how any prepaid fees will be calculated and refunded
when Participating Employer withdraws from the Plan.
(b) Whether any Service Provider will provide any services to the Plan as a fiduciary either within the meaning of Section 3(21) of ERISA or under the
Investment Advisers Act of 1940.
(c) Whether any Service Provider expects to participate in, or otherwise acquire a financial or other interest in, any transaction to be entered into by the
Plan and, if so, a description of the transaction and the Service Provider’s participation or interest therein.
(d) Whether any Service Provider has any material financial, referral, or other relationship or arrangement with a money manager, broker, other client of
the Service Provider, other service provider to the Plan, or any other entity that creates or may create a conflict of interest for the Service Provider in
performing services to the Plan and, if so, a description of such relationship or arrangement.
(e) Whether any Service Provider will be able to affect its own or another Service Provider’s compensation or fees, from whatever source, without the
prior approval of an independent fiduciary of the Plan, in connection with the provision of services to the Plan (for example, as a result of incentive,
performance-based, float, or other contingent compensation) and, if so, a description of the nature of such compensation.
(f) Whether any Service Provider has any policies or procedures that (i) address actual or potential conflicts of interest or (ii) are designed to prevent
either compensation or fees or any other business ventures or relations that may be entered into between the Plan and a Service Provider, from
adversely affecting a Service Provider’s ability to provide services under the Service Agreements, and, if so, an explanation of these policies or
procedures and how they address such conflicts of interest or prevent an adverse effect on the provision of services.
The Trustee shall disclose or cause to be disclosed to the Responsible Plan Fiduciary any material change to the information disclosed above not later than
30 days from the date on which the Service Provider acquires knowledge of the material change. The Trustee shall also disclose or cause to be disclosed all
information related to the Service Agreements and any compensation or fees received there under that is requested by the Responsible Plan Fiduciary or
administrator of the Plan in order to comply with the reporting and disclosure requirements of Title I of ERISA and the regulations, forms, and schedules
issued there under.
CB 0210A 11/2020 Eff. 3/1/2021
License # 0N14196 – ChoiceBuilder Insurance Services