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ORDER FORM No., I for The City of South Bend, Indiana <br />This order form, effective January 1, 2018 (tile "Order Form Effective Date") is an addendum to, and constitutes a part of, the <br />License and Services Agreement between Service Company and Client dated December 11, 2018. By this Order Form, Client <br />purchases the following: <br />LICENSE, MAINTENANCE, AND SUPPORT FEES <br />Est. Total <br />Monthly <br />Monthly License, <br />License, <br />Client Service &/or <br />Approximate <br />Maintenance <br />Maintenance <br />linplententation <br />Application SoftwaYe <br />Number of Eligible <br />and Support Fees <br />and Support <br />Fees or Other One <br />Annual Base <br />Title <br />Employees* <br />(PEPM) <br />Fees <br />Thne Fees <br />Renewal Fee <br />Benefits Open <br />Enrollment and <br />1,200 <br />$3.50 <br />$4,200.00 <br />$0 <br />$0 <br />Administration <br />Services <br />* These numbers represent the current number of Client's employees as of the date of this Agreement. On or about the I' of each month, Service Company <br />will generate a count of benefits eligible employees from the BenXpress enrollment system as of that date. Client's Total Monthly License, Maintenance and <br />Support Fees will be determined by multiplying the number of employees by the PEPM License, Maintenance and Support Fee. Thus, the amount Client will <br />be charged monthly will vary based upon the actual number of employees and may be more or less than the numbers indicated in the table above. <br />ADDITIONAL TERMS <br />L Billing. Billing of the Monthly License, Maintenance and Support Fees detailed in this Order Form will <br />commence on January 1, 2018, <br />I Term. This Agreement shall commence on the Order Form Effective Date and shall continue through <br />December 31, 2019 ("Full Agreement Term"). This agreement will automatically renew additional I year <br />periods unless either party provides tile other party with 90 days prior written notice of its intent to terminate <br />prior to the end of the applicable term. <br />3. Licensed Users, The total number of user identification numbers and passwords to be issued to Licensee will be <br />based upon the actual number of benefit eligible employees and authorized administrators. <br />4. Changes in Fees and Rates. Service Company agrees to honor the fees and rates provided in this Order Form <br />through December 31, 2017, Company reserves the right to modify said fees, and rates if this Agreement and <br />Order Form have not been executed by Client by said date. <br />S. Client Service, Customization Fees shall be provided as set forth in Exhibit A, if applicable, <br />C. Proiect Contacts. <br />Send Invoice To: <br />Tierra Davis <br />tddavis@southbendin,gov <br />(574) 235-5510 <br />AccordWare Client Account Manager <br />Brigette Heck <br />blieck @)accordwarexom <br />248-822-7777 ext. 4009 <br />248-822-7377 (fax) <br />Miscellaneous. Any printed and mailed conurtunications will be quoted and billed to Client on an as <br />needed basis. Design and development of standard Service Company communication material is included <br />in the above quoted fees. Any pre -approved travel expenses will be billed to Client. Customization <br />beyond the standard allowable custornization will be billed at an hourly rate of $150/hour. <br />COSB Order Form 1 Confidential Page 7 of 10 <br />