Request for HSA Feasibilty Study

To: Self-Funding Actuarial Services, Inc.

8025 North Point Blvd, Suite 207W, Winston-Salem, NC 27106

From: _______________________________ By: ___________________

A. Items Needed by the Actuary

1. Both the historical claims experience (ideally the aggregate tracking report)

and detailed terms of renewal.

2. Profiles of plan benefits for ending year and for upcoming plan year with

indications of options, networking non-core benefits, etc.

3. Elections by Plan Sponsor

a. Projections are to (include) (exclude) retired participants.

b. Monte Carl Simuations of present plan (should) (should not) be provided.

c. HSA Options are Either (i) or (ii) below:

i. Only the HSA is offered but with the following deductibles available to the participant:

_________ $1,000

_________ $2,600 + 50% of the nect $4,800

_________ $5,000

_________ Other __________

ii. The HSA is offered as an option to the present plan with the following deductibles:

_______________ _______________ _______________

B. Work Product

The HSA Feasability Study, posted at www.hsaplanning.com, is the standard work product. It may be modified as the practitioner sees fit in order to meet the needs of the plan sponsor.

C. Fees and Terms

1. Turnaround tome is 2-4 days.

2. Fees are as follows:

Work Product	Cost Per Participant	Minimax
Annual Actuarial Report	$1	$200-$1,000
Monte Carlo Simulations	$1	$200-$1,000
HSA Feasibility Study
HSA Option Only	$2	$200-$1,000
HSA Option and Present Plan	$2	$200-$1,000

Additonal fees of 25% will apply to multiple risk pools (high v. low options, active v. retirees, e.g.). Fees anticipate no more than three deductibles.

a. A small plan, with the Monte Carlo Simulation, and two HSA options would have a $600 fee.

b. A very large plan, with the Monte Carlo Simulation, and two HSA options would have a $4,000 fee.

3. Incoming communications either by e-mail or fax are acceptable: