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1724 Benefit FocusPursuant to the terms and conditions set forth in the Client Services Agreement ( "Agreement") bet10�'N ( "Benefitfocus ") and City of Sanford, Florida ( "Client') (collectively the "Parties ") and this Order F� /%��� /;i� ,// : 1� Benefitfocus will provide to Client those IRS Reporting Services identified and marked with an "X" in Section CI for the fees indicated. 1 Client +Ihformation,,,_u. u NewCl�ent, . ®,Existin Client S stem lnte rator, Im lementationw , -- ,'p Resel er , ,,, -,,, . ;; 1. Client Name: City of Sanford, Florida I 2.Address: On File 3. Effective Date: September 15, 2015 4. End of Initial Term: March 31, 2017 5. Employee Count: On File 6. Account Executive: Sharon Alexander 7. Solutions Engineer: William Jankins 8. Client Contact (name, email): Fred Fosson, 9. Invoice Contact (name, email, address, and county): On fossonf @sanfordfl.gov File 10. Duplicate Invoice: (Yes /No) No 11.Duplicate Invoice Contact Information (name, email, address): Not A plicable �109MCJ1095 G Internal Revenge Servtce,(IRS)1ReportmgServices„ x ;;. , , - , s�.. ,.,��,..... .._` � .....: <' _ .. .... :. .. .. . . = -..r • - - -.. „II Fees Service A. Standard IRS Reporting Services: $0 (Waived) • For the 2015 Reporting Period $3.00 per employee per year ("PEPY") • For Each Additional Reporting Period B. [] Optional Data Support Services Scope Not n Scope i C. p Paper Fulfillment Services Not in Scope D. Ongoing Software Services Terms and Conditions 1. Standard IRS Reporting Services. The PEPY fee for the Standard IRS Reporting Services is waived for the 2015 IRS Reporting Period. Benefitfocus will invoice Client for the PEPY fee for the 2016 IRS Reporting Period on January 1, 2016 and, provided Client renews, each January 1 thereafter for the remainder of the Order Form term at the above PEPY rate. For the 2016 IRS Reporting Period and each additional Reporting Period thereafter, Benefitfocus will also determine the difference between the number of employees invoiced by Benefitfocus as of January 1 of the applicable Reporting Period and the actual number of employees electronically submitted to the IRS following such Reporting Period, and, to the extent the number of employees electronically submitted to the IRS is higher, then Benefitfocus will also invoice Client for the additional number of employees electronically submitted to the IRS multiplied by the above PEPY rate. 2. Definitions: a. "Optional Data Support Services" means the Optional Data Support Services defined in Appendix A. b. "Paper Fulfillment Services" means the Paper Fulfilment Services defined in Appendix A (if included). C. "Reporting Period" means the calendar year (January 1 through December 31) for which the employee data will be collected for the Standard IRS Reporting Services for the year(s) selected above. Data collected during this time period shall be reported by the applicable IRS deadlines the following calendar year. d. "Standard IRS Reporting Services" means the Standard IRS Reporting Services defined in Appendix A. e. "2015 IRS Reporting Period" means the 2015 calendar year. The collected data shall be reported by the applicable IRS deadlines in 2016. f. "2016 IRS Reporting Period" means the 2016 calendar year. The data shall be reported by the applicable IRS deadlines in 2017 3. Optional Data Support Services. Client may subsequently request the Optional Data Support Services for the 2015 IRS Reporting Period, provided that Client executes and delivers a subsequent Order Form to Benefitfocus not later than October 1, 2015. Th e $7,500 one -time fee includes up to 40 hours of Optional Data Support Services, and additional Optional Data Support Services hours may be requested by Client at the rate of $165 per hour for the 2015 IRS Reporting Period. Client may later request to purchase Optional Data Support Services for the 2016 IRS Reporting Period and additional Reporting Periods, which will also require a subsequent Order Form signed by the parties. 4. At the End of the Initial Term, and any renewal term thereof, the IRS Reporting Services shall automatically renew for additional one (1) year terms (each a "Renewal Term "), unless either party provides written notice of its intent to not renew not less than ninety (90) days prior to the end of the then current term. Upon conclusion of the Initial Term, and provided Client renews this Order Form, Benefitfocus reserves the right to increase fees by up to 3% on an annual basis. <<SIGNATURE PAGE FOLLOWS>> ©2015. Benefitfocus.com, Inc. Page 1 of 4 CONFIDENTIAL & PROPRIETARY All rights reserved (8118/15) v.1 ORDER FORM: IRS Reporting Services BENEEITE G -CUS" This Order Form is accepted and agreed to by: BENEFITFOCUSA/OJOANC. By: PC/'ERAT TtCHIEF f LT-NA JNCiAL OFFICER Date: v-N i CITY OF SANFORD, FLORIDA By: SEE ATTACHED SIGNATURE PAGE -- Print: Title: Date: (Signature Page of Order Form) @2015. Benefiftcus.com, Inc. Page 2 of 4 CONFIDENTIAL & PROPRIETARY All rights reserved (8118/15) v.1 ORDER FORM: IRS Reporting Services 6ENEFITF ACUS' Appendix A This Appendix A defines: (1) a high level overview of the functionality of the 1094- C/1095 -C IRS Reporting Services (the "IRS Reporting Services ") specified in the Order Form between Client and Benefitfocus. 1094 -C /1095 -C IRS Reporting Implementation Services: Anticipated dates for implementation and deployment will be determined during technical discovery. The below services require technical discovery and configuration and will occur sometime after configuration of the Benefitfocus Marketplace and may require coordination with the Benefitfocus software release schedule. A. Standard IRS Reporting Services. For the applicable Reporting Periods, Benefitfocus will provide Client with the ability to load the applicable data required for the current Reporting Period within a self - service file upload tool in order to populate the 1095 -C Forms, and utilizing the standard Benefitfocus file format and specifications (the "Standard iRS Reporting Services "). B. Optional Data Support Services. For the applicable Reporting Periods, Client has the option, at the rates and deadlines set forth herein, to request that Benefitfocus provide additional assistance to help Client format the required data provided by Client into the standard Benefitfocus file format and specifications required for self - service file uploading and /or address applicable data exceptions resulting from such file upload (the "Optional Data Support Services "). C. For the above services, Benefitfocus will: a. Conduct a discovery call with Client b. Provide specifications to Client on a required file format(s) and data fields c. Review process workflow and define error resolution procedures d. Determine and document schedule for implementation, testing, and deployment e. Conduct testing in a test environment I!. 1094- C/1095 -C IRS Reporting Software Services: A. 1095 -C Forms. For the applicable Reporting Periods, Benefitfocus will provide: a. An electronic version of the 1095 -C Form, populated with Client - specific employee data, in PDF format and made available for Client download /printing, and a report delivered by Benefitfocus to Client, in xml file format, for Client's submission to the IRS or other third party designated by Client. B. 1094 -C Forms. For the applicable Reporting Periods, Benefitfocus will provide an electronic version of Client's 1094 -C Form, populated with Client - specific employee data, within the Benefitfocus Marketplace in PDF format and a report delivered by Benefitfocus to Client, in xml file format, for Client's submission to the iRS or other third party designated by Client. C. IRS Submission. To the extent that Benefitfocus is authorized and permitted to do so by the IRS, upon Client's request, Benefitfocus shall submit the 1095 -C and 1094 -C Forms to the IRS on behalf of Client for the applicable Reporting Periods. Client acknowledges that the iRS and other Federal agencies with jurisdiction over the above Reporting Services have not issued final regulations implementing the requirements for electronic submission of the 1094- C/1095 -C Forms directly to the iRS by third parties, such as Benefitfocus. Until such time as the IRS Issues such final regulations, Benefitfocus will provide the electronic version of the 1094 -C /1095 -C data to Client for Client - submission to the iRS. Upon the iRS issuing the final regulations for the Reporting Services, and Benefitfocus' qualification and authorization to submit on behalf of Client, Benefitfocus will electronically submit the required 1094 - 0095 -C data to the iRS on behalf of Client. Benefitfocus shall utilize commercially reasonable efforts to achieve such qualification and authorization, provided however, that (i) Benefitfocus is under no obligation to materially change its corporate structure or to obtain other professional or business licenses (including without limitation designation as a tax preparer or other professional organization by the IRS), and (ii) the final IRS requirements are published with reasonable advance notice to permit Benefitfocus to obtain appropriate qualifications and authorizations to perform the data submission to the IRS, and to comply with any applicable technical requirements related to submission of the data to the IRS" other applicable Federal agency. Ill. Terms and Conditions: A. For the applicable Reporting Periods, there is a minimum sixty (60) day testing period for the Standard IRS Reporting Services and Optional Data Support Services. All required data for the IRS 1095 -C Forms must be provided, loaded, signed - off on and finalized by Client not later than January 7 of the calendar year following the applicable Reporting Period in order for Benefitfocus to make the electronic version of the 1095 -C IRS Forms available within the Benefitfocus Marketplace on or before the applicable due date required by the iRS. By way of example, for the 2015 iRS Reporting Period, Client must upload the final version of the required data within Benefitfocus Marketplace by January 7, 2016 in order for Benefitfocus to make the electronic versions available as of February 1, 2016. B. The data format Client will utilize to review the loaded data during testing will be provided in .csv file format only. ©2015. Benefitfocus.com, Inc. Page 3 of 4 CONFIDENTIAL & PROPRIETARY All rights reserved (8118/15) v.1 [ ORDER FORM: IRS Reporting Services BE EEITE02CUS`' C. Client shall be responsible for providing and uploading the required data, utilizing the standard Benefitfocus file format and specifications, and validating the accuracy of the uploaded data. Upon Client uploading the required data via the self - service file upload tool, Client may make corrections to the loaded data by manually correcting such data within the Benefitfocus Marketplace user interface or uploading additional employee demographic data files via Client's payroll interface or the self - service file upload tool. D. Client acknowledges that the above 1094 -C /1095 -C IRS Forms will only contain data for Client's medical benefit(s) as configured within the Benefitfocus Marketplace (i.e. excludes all other benefit types). E. Access to electronic versions of the 1095 -C Forms will only be provided to Client's actively- employed employees ( "Active Employees "), which shall exclude employees designated with a "COBRA ", `Terminated ", or "Leave of Absence" status within or are otherwise not provided access to the Benefitfocus Marketplace ( "Inactive Employees "). Access to electronic versions of the 1095 -C Forms will not be provided to Inactive Employees, or in the event Client terminates the Benel'itfocus Marketplace services prior to the applicable Reporting Period deadline. If Client does not purchase the Paper Fulfillment Services, then Client is responsible for printing and mailing such 1095 -C Forms to its Inactive Employees, or in the event it terminates the Benefitfocus Marketplace services prior to the applicable reporting deadline, at its own cost and expense. If Client purchases the Paper Fulfillment Services, then Benefitfocus will mail the 1095 -C Forms to all Active Employees and Inactive Employees loaded within the Benefitfocus Marketplace as a part of the Paper Fulfillment Services. F. To the extent Client has purchased the Benefits Service Center ( "BSC') call center support, Benefitfocus will respond to member inquiries related to the 1095 -C /1094 -C Forms pursuant to the mutually agreed upon member support call script. In the event Client has not purchased BSC call center support, Benefitfocus will advise members to contact the Client - designated representative for inquiries related to the 1095- C/1094 -C Forms. ©2015. Benefitfocus.com, Inc. Page 4 of 4 CONFIDENTIAL & PROPRIETARY All rights reserved (8/18115) v.1 ATTEST.- CYW IA PORTER CITY CLERK APPROVED AS TO FORM AND LEGALITY: CITY ATTORNE ly Clq CITY OF SANFORD