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Post Employment Health Plan (PEHP) <br /> Disclosure and Acknowledgment Form <br /> As with atl plans receiving favorable tax treatment under the internal Revenue Code, the <br /> Nationwide Post Employrrment Health Plan (PEHP�) offers you and your employees' <br /> significant benefits that aiso come with important limitations. Your Nationwide <br /> representative is prepared to help you understand the Plan's benefits and limitations. <br /> Please understand Nationwide nor its representatives may give legal or tax advice. You <br /> should consult with your legal and tax advisers before making decisions about <br /> establishing PEHP for your employees. <br /> PEHP is funded through a voluntary employees' beneficiary association (VEBA), a tax- <br /> exempt trust authorized by IRC Section 501 C (9). PEHP, as a health reimbursement <br /> arrangement (HRA), must also comply with the regulatory requirements of HRAs. PEHP is <br /> not a retirement pian nor is it a deferred compensation plan.To operate within IRS <br /> requirements, PEHP must comply with requirements different than those of retirement <br /> plans. Some of those requirements include the following: <br /> Please read and initial the following: <br /> 1,1� � � � Contributions must be made solely by the Employer. Salary deferrals by <br /> employees are not permitted, however, contributions of unused vacation and sick <br /> leave conversion benefits are permitted. <br /> 2. I' ' � � Benefits paid from the Qualifying Medical Care Expense Sub-account may <br /> not discriminate in favor of highly compensated employees. Only equal dollar <br /> amount contributions to this Sub-account for all Eligible Employees will be accepted. <br /> 3. �� PEHP is not permitted to accept beneficiary designations. Following an <br /> Eligibfe Employee's death, payment of benefits is limited to the Employee's surviving <br /> spouse and legal dependents. Any account balance remaining after the death(s) of <br /> the Employee, any spouse or legal dependents will be allocated among your , <br /> remaining participating Employees. <br /> 4. 1� `��PEHP does not provide a mechanism for plan transfers to any product <br /> including other VEBAs. A Participating Employer may withdraw from participation in <br /> PEHP by notifying Nationwide its contributions will cease, but assets must be <br /> maintained within the PEHP VEBA trust. <br /> N RI-0209A0-0408 <br /> �02008, Nationwide Retirement Solutions. <br /> Nationwide,the Nationwide Framemark, On Your Side <br /> and PEHP are federally registered service marks of <br /> Nationwide Mutual Insurance Company. <br />