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WorksiteNolutitary Benefits (VB): Future implementation of worksite/voluntary benefits may incur the <br />following fees: $250.00 build fee for (Accident, Hospital Indemnity, Critical Illness, Supplemental <br />Disability), $750.00 build fee (Whole Life-Unurn Only)�, and a $0.25 PEPM fee for ongoing <br />administration of these benefits, <br />The parties have caused this Order Form to be executed by their duly authorized representatives as of the date <br />last signed below. <br />Tm CITY OF SOUTH BEND, INDIANA AccoRDWARF. LLC <br />By: <br />Name: <br />Title: <br />Date: <br />By <br />Name: Matthew C. Czmer <br />Title: Member <br />Date: December 11, 2017 <br />COSB Order Form 1 Confidential Page 8 of 10 <br />