Submit Elections Confirmation

06:00 AM 03/24/2014 Page 1 of 2

Hire for Bush, Samantha Miriam Valtierra Initiated On: 02/27/2014 Submit Elections By: 03/19/2014 Event Date: 02/17/2014

$115.66 Monthly Cost Total Employee Cost/Credit

Elected Coverages
Benefit Plan MNG Medical - Kaiser DHMO MNG Basic Life/AD&D - Cigna - 50k Max (Employee) Coverage Begin Date 05/01/2014 05/01/2014 Deduction Begin Date 05/01/2014 05/01/2014 Coverage Employee Only 1 X Salary Total: Calculated Coverage Dependents Beneficiaries Employee Cost (Monthly) $115.66 $39,000.00 $115.66 Employer Contribution (Monthly) $269.90 $4.45 $274.35

Waived Coverages
Plan Type MNG Dental MNG Vision MNG Health Savings Account Healthcare FSA Dependent Care FSA Parking SA Commuter SA MNG Supp Life/AD&D MNG Supp Life/AD&D Spouse MNG Supp Life Child MNG Voluntary LTD

Beneficiary Designations
Benefit Plan MNG Basic Life/AD&D - Cigna - 50k Max (Employee) Electronic Signature By clicking AGREE, I affirm that all information I have provided is full, complete and true to the best of my knowledge, and I authorize deductions and required contributions to be taken from my pay on a pre or post tax basis, as appropriate, to implement my benefit elections. I understand that a change in coverage must be due to and consistent with a change in family status as permitted by applicable law and regulations. Examples of such change in family status include marriage, divorce, death of a spouse or child, birth or adoption of a child or termination of employment of spouse. Change in enrollment must be made within 31 days of any qualifying event by the employee through their Workday self-service account. Requires Beneficiary Beneficiaries

Submit Elections Confirmation

06:00 AM 03/24/2014 Page 2 of 2

I understand that my elections are effective through December 31 of the current year, unless my enrollment is during the annual open enrollment period, in which case, my elections are for the next plan year and that I cannot make changes to certain benefits unless allowed under the plan or unless I experience a qualified status change during the year. If I have declined any available coverage, I will not be covered by these group benefit plans and cannot enroll in them until the next annual enrollment period, unless I experience a qualified status change. If I have elected to make contributions to the Flexible Spending Accounts (FSA), I understand that I will forfeit credits/dollars remaining in the accounts on the last day of March of the following year that have not been used for reimbursement or eligible plan expenses incurred during the calendar year beginning in January and ending in December of the current year. I hereby designate the beneficiary(ies) listed above and understand that I have the right to change these beneficiary designations in accordance with the provisions of the plan. These beneficiary designations supersede any previous designations. Signed By: Bush, Samantha Miriam Valtierra Date: 03/24/2014