Document:

Exhibit 4.50

 

English Translation

 

 

Subscription Agreement

 

For

 

Private Placement Shares

 

Of

 

China Eastern Airlines Corporation Limited

 

 

 

 

 

______, 2016

 

 

English Translation

 

 

Subscription Agreement for Private Placement Shares of China Eastern Airlines Corporation Limited

 

This Agreement is entered into as of ______, 2016 by and between:

 

Party A: China Eastern Airlines Corporation Limited
  Registered Address: 66 Airport Avenue, Pudong International Airport, Shanghai
 Business Address: 2550 Hong Qiao Road, Shanghai
 Legal Representative: Liu Shaoyong

 

Party B: Shanghai Licheng Information Technology Consulting Co., Ltd.
  Legal Representative: Xiong Xing
 Contact: Lu Zuying
 Tel: (021) 34064880 ext.: 12786
 Registered Address: Section C, 5/F Block 1, 99 Fu Quan Road, Changning District, Shanghai

 

WHEREAS:

 

1.        China Eastern Airlines Corporation Limited (the “Issuer,” “Party A” or “China Eastern”), a company limited by shares duly incorporated and listed on Shanghai Stock Exchange, has had its plan to issue, through private placement, up to (and including) 2,329,192,546 shares (the “Private Placement”) deliberated and adopted at its 2014 annual shareholders’ meeting, and ratified and approved by China Securities Regulatory Commission (“CSRC”) with a document titled Approval on Private Placement of Shares by China Eastern Airlines Corporation Limited and numbered Zheng Jian Xu Ke [2016] No. 8.

 

2.        In connection with the matters regarding the Private Placement, China Eastern has engaged China International Capital Corporation Limited (the “Sponsor/Joint Lead Manager” or “CICC”) as the sponsor/ joint lead manager of the Private Placement, and Credit Suisse Founder Securities Limited (the “Joint Lead Manager” or “CSFS”) and Everbright Securities Co., Ltd. (the “Joint Lead Manager” or “EB Securities”) as joint lead managers of the Private Placement.

 

3.        The book-building of the Private Placement was completed on June 16, 2016, pursuant to which it has been finally determined that 1,327,406,822 shares are to be issued under the Private Placement at a price of RMB6.44 per share (with a par value of RMB1 per share).

 

4.        Party B is a qualified investor under relevant CSRC rules and resolutions of China Eastern relating the Private Placement, and is aware of all the information relating to the Private Placement disclosed by China Eastern. Party B has been confirmed as the final target after the placement made by the Joint Lead Managers in accordance with relevant CSRC rules and purchase and placement procedures and rules.

 

Based on the above and in accordance with the provisions of the Company Law of the People’s Republic of China, Securities Law of the People’s Republic of China, Administrative Measures for the Issuance of Securities by Listed Companies and such other pertinent laws and regulations, to set forth the respective rights and obligations of Party A and Party B in connection with the Private Placement, Party A and Party B, upon mutual consultations, hereby agree as follows with

 

1

 

English Translation

 

 

respect to the relevant matters regarding Party B’s subscription of the shares issued under Private Placement of Party A:

 

Article 1: Number of Shares Subscribed, Subscription Price and Payment of Subscription Consideration

 

1.      Number of Shares Subscribed. Subject to the condition that Party B has received the invitation for subscription from Party A and replied to the Quotation for Share Purchase attached thereto, the Parties agree, based on Party B’s intention of purchase and the book-building results of the Private Placement, that Party A will issue 465,838,509 shares to Party B (being the specific target of the Private Placement).

 

2.      Subscription Price. The subscription price shall be RMB6.44 per share.

 

3.      Total Amount of Subscription Consideration. Party B agrees that the total consideration for the subscription of shares shall be RMB2,999,999,997.96 (Renminbi two billion nine hundred and ninety-nine million nine hundred and ninety-nine thousand nine hundred and ninety-seven Yuan ninety-six cents).

 

4.      Means of Payment. After this Agreement becomes effective, Party B shall pay the full amount of the subscription consideration set forth herein to the account designated by the Joint Lead Managers of the Private Placement pursuant to the timeline provided in the payment notice delivered by the Joint Lead Managers.

 

Article 2: Rights and Obligations of Party A

 

(I)                          Rights of Party A

 

1.        Party A may require Party B to assist China Eastern in the application of the Private Placement, and provide true, accurate and complete materials in accordance with the CSRC requirements governing the application documents.

 

2.        Party A may require Party B to promptly inform Party A upon the occurrence of any significant event that falls within the scope of disclosure stipulated by CSRC and Shanghai Stock Exchange.

 

3.        Party A may require Party B to pay the entire subscription consideration within the time period provided in the payment notice.

 

(II)                    Obligations of Party A

 

1.        Party A guarantees that the application documents for securities issuance submitted to CSRC are true, accurate, complete and free of false records, misleading statements or material omissions.

 

2.        Party A guarantees to promptly inform Party B upon the occurrence of any significant event that falls within the scope of disclosure stipulated by CSRC and Shanghai Stock Exchange.

 

2

 

English Translation

 

 

3.        Party A shall go through the procedures to register the relevant shares according to relevant laws and regulations as soon as practicable after Party B has paid subscription consideration pursuant to this Agreement.

 

4.        Any other obligation that should be assumed by Party A in connection with the Private Placement as required by law or administrative regulations or as agreed by the Parties upon consultation.

 

Article 3: Rights and Obligations of Party B

 

(I)                          Rights of Party B

 

1.        Party B may require that the application documents for securities issuance submitted to CSRC by Party A be true, accurate, complete and free of false records, misleading statements or material omissions.

 

2.        Party B may require Party A to promptly inform Party B upon the occurrence of any significant event that falls within the scope of disclosure stipulated by CSRC and Shanghai Stock Exchange.

 

3.        Any other rights that are entitled by Party B in accordance with laws, regulations and other relevant policies.

 

(III)              Obligations of Party B

 

1.        Party B warrants and covenants that it owns the intention, qualification and capabilities to subscribe for the shares issued by the Issuer under the Private Placement, has obtained necessary authorizations and approvals for such subscription, and such subscription will not violate or conflict with the provisions of any applicable current laws, regulations or regulatory documents, or other contracts or agreements to which it is a party.

 

2.        Party B shall assist Party A and the Sponsor in the application of the Private Placement, and provide true, accurate and complete materials in accordance with the relevant requirements of CSRC, Shanghai Stock Exchange, China Securities Depository and Clearing Company Limited (CSDCC) Shanghai Branch and such other competent authority.

 

3.        Party B shall promptly inform Party A upon the occurrence of any significant event that falls within the scope of disclosure stipulated by CSRC and Shanghai Stock Exchange.

 

4.        Party B covenants that Party B and its final subscribing entity will not include Party A and its subsidiaries, controlling shareholders, de-facto controller or any affiliate controlled by it, directors, supervisors, officers, Joint Lead Managers and any other parties otherwise affiliated with any of the foregoing, and none of the foregoing entities or persons will participate in the subscription in connection with the Private Placement indirectly through Party B.

 

3

 

English Translation

 

 

5.        Party B shall pay the full amount of the subscription consideration within the time provided in the payment notice and guarantee that all the capitals used to pay the subscription consideration of the Private Placement are from legitimate source and in compliance with relevant CSRC rules; otherwise, all consequences thus brought about shall be fully borne by Party B.

 

6.        Other obligations that should be assumed by Party B as required by laws and administrative regulations or as agreed between the Parties.

 

Article 4: Lockup Period

 

Party B acknowledges that the lockup period for the new shares subscribed in the Private Placement shall be twelve (12) months from the completion of the Private Placement, during which no shares may be listed or transferred.

 

Article 5: Confidentiality

 

Both Parties guarantee that unless a disclosure to a third party or to the public is required for purposes of processing approval and recordation procedures with competent government authorities or regulatory securities departments pursuant to relevant laws, regulations and department rules, or for the performance of their respective obligations or representations and warranties hereunder, each Party agrees, and shall cause relevant persons having access, to keep in strict confidence all the provisions hereof and matters regarding the Private Placement, and not to provide such information to any third party in any manner or through any source whatsoever without the consent of the other Party.

 

Article 6: Liabilities for Breach

 

1.      In the event that a Party is in breach of any PRC law or relevant provision hereof and thus causes loss to the other Party, then such other Party (being the non-defaulting Party) shall be entitled to claim damages, and the defaulting Party shall indemnify the non-defaulting Party, for such loss as actually incurred.

 

2.      Notwithstanding the foregoing, Party B’s failure to pay Party A the full amount of the subscription consideration within the time provided in the payment notice after this Agreement becomes effective shall be deemed as its waiver of the right to subscribe for the shares issued under the Private Placement, in which case Party A may negotiate with the Sponsor and the Joint Lead Managers with respect to the treatment of such shares, and the security deposit already paid by Party B for the subscription will become part of the penalty fine to be owned by Party A, non-refundable to Party B.

 

Article 7: Assignment and Waiver

 

1.      Neither Party may assign any of its rights or obligations hereunder.

 

2.      During the term agreed herein, no failure by a Party to exercise any of its rights hereunder shall constitute or be construed as its waiver of such right, nor will it preclude in any respect the subsequent exercise of such right by such Party.

 

4

 

English Translation

 

 

Article 8: Notices and Delivery

 

All notices hereunder shall be delivered in written form, including via fax, email or mail, which shall be deemed duly served upon signed and accepted by the addressee; notices sent in person shall be deemed duly served when left at the address of the addressee.

 

Article 9: Dispute Resolution

 

Any dispute arising hereunder shall first be resolved through amicable negotiations between the Parties. If the dispute fails to be resolved through negotiations within fifteen (15) days after either Party’s written notice to the other specifying such dispute, either Party may bring a lawsuit to the People’s Court of competent jurisdiction over the domicile of Party A.

 

Article 10: Effectiveness, Term and Termination

 

1.      This Agreement shall become effective upon affixed with signature and official seal of the legal representatives of the Parties or their respective authorized representatives.

 

2.      This Agreement shall terminate, without imposing any legal liabilities for either Party, if:

 

(1)                              both Parties have completed their respective obligations hereunder; or

 

(2)                              the Private Placement by the Issuer fails; or

 

(3)                              an event of force majeure occurs during the performance of this Agreement.

 

Article 11: Uncovered Matters

 

1.      Any matters not covered herein shall be subject to a supplementary agreement separately entered into between the Parties through negotiations, which shall be equally binding as this Agreement.

 

2.      Any supplement or amendment to this Agreement shall be made by both Parties in writing.

 

Article 12: Counterparts

 

This Agreement shall be made in four counterparts, all being equally binding after signed by both Parties on separate signature pages. Each Party shall hold one original and the remaining two shall be used for filing or recordation purposes.

 

 

 

(The remainder of this pages is intentionally left blank)

 

5

 

English Translation

 

 

(This page contains no body text and is the signature page of Subscription Agreement for Private Placement Shares of China Eastern Airlines Corporation Limited)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

China Eastern Airlines Corporation Limited (seal)

 

	
Legal Representative (or Authorized Representative):
    	
/s/ Yongliang Wu
    

 

Date:

 

 

English Translation

 

 

(This page contains no body text and is the signature page of Subscription Agreement for Private Placement Shares of China Eastern Airlines Corporation Limited)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Subscriber (seal): Shanghai Licheng Information Technology Consulting Co., Ltd.

 

Legal Representative (or Authorized Representative): Xiong Xing

 

Date: June 27, 2016Exhibit 10.66

 

ASTORIA
Bank

Amended and Restated

RETIREMENT MEDICAL, DENTAL AND VISION BENEFIT PLAN FOR

SENIOR OFFICERS (CoRporate VICE PRESIDENTS & ABOVE)

 

Purpose

 

Astoria Bank (f/k/a Astoria Federal Savings
and Loan Association), a federal savings association (the “Bank”), will provide retirement medical, dental,
and vision insurance benefits for employees of the Bank with a Corporate Officer title of Vice President and above (each, an “Eligible
Officer”), spouse, and eligible dependents, subject to the eligibility provisions of this Amended and Restated Retirement
Medical, Dental and Vision Benefit Plan for Senior Officers (Corporate Vice Presidents & Above) (this “Plan”).

 

Eligibility

 

Eligible Officers who upon the date of termination of
employment (a “Retirement Date”) with the Bank are at least 55 years of age and have at least ten
years of service will be eligible for benefits under this Plan. On the one year anniversary of the consummation of a
“Change in Control” (as defined in the 2014 Amended and Restated Stock Incentive Plan for Officers and Employees
of Astoria Financial Corporation), the ability for any individual to satisfy the eligibility requirements for participation
shall be frozen with the result that no individual shall be eligible for benefits under this Plan who has not satisfied as of
the one year anniversary of the Change in Control the minimum age and service eligibility requirements set forth in this
Plan, taking into account for purposes of age and years of service any imputed service described in the immediately following
sentence. When calculating age and service for purposes of determining eligibility to participate and the percentage of the
cost of coverage paid by the Bank under this Plan, an Eligible Officer who is party to an Employment Agreement or Change of
Control Severance Agreement with the Astoria Financial Corporation and/or the Bank as of the date of termination and who
receives separation payments under such agreement in connection with his or her termination of employment will be deemed to
have remained in the service of the Bank through the last day of the applicable “Remaining Unexpired Employment
Period” (as defined in the Employment Agreement) or “Assurance Period” (as defined in the Change of Control
Severance Agreement).

 

    	 	 	 

     

    

 

Coverage

 

Coverage pursuant to this Plan will be provided
for (1) each Eligible Officer who satisfies the eligibility requirements described above (a “Participant”)
for his or her lifetime; (2) such Eligible Officer’s spouse (each such person, a “Eligible Spouse”)
as of the applicable Commencement Date (as defined below) for his or her lifetime; provided that, if such Eligible Officer
predeceases his or her Eligible Spouse and such Eligible Spouse remarries, such Eligible Spouse shall cease to be covered under
this Plan as of the date of such remarriage; and (3) dependents of such Eligible Officer and his or her Eligible Spouse to
the extent eligible under the applicable Standard Plans (as defined below). Coverage will not be provided for a spouse or for any
dependents arising from a marriage or remarriage of the Eligible Officer that occurs following the applicable Commencement Date.
An Eligible Officer who satisfies the eligibility requirements described above may commence coverage under this Plan at any time
following his or her termination of employment and prior to his or her death (the date on which an Eligible Officer commences coverage,
a “Commencement Date”); provided that such Eligible Officer elects at the time of his or her termination
of employment to commence or defer his or her benefits in accordance with an election form substantially in the form attached hereto
as Exhibit A, If an Eligible Officer who has elected to commence coverage under this Plan later terminates such coverage,
he or she may not re-commence coverage under this Plan after such termination of coverage.

 

A Participant who is employed elsewhere
shall not be required to cease coverage under this Plan; provided that coverage under this Plan shall be secondary to any coverage
provided to the Participant as a result of such other employment.

 

On the applicable election form, a Participant
may elect medical coverage, dental coverage, vision coverage, or any combination thereof. During the annual open enrollment period,
a Participant may change elections. Enrollment in Medicare is required for any Participant who is at least age 65 and no longer
working. Enrollment in Medicare is also required for any spouse or dependent who is at least age 65 if this Plan provides primary
coverage to such spouse or dependent. Any and all Medicare costs are paid 100% by the Participant or any spouse or dependent who
is required to be enrolled in Medicare.

 

All or a portion of the Participant’s
cost of coverage under this Plan for a Standard Plan as indicated on Exhibit B shall be paid by the Bank based on the Participant’s
age as of the Retirement Date (which, for the avoidance of doubt, shall take into account any imputed service) based on the following
schedule:

 

	
         Retirement
Age
	
        Percentage
        Paid by Bank

	55	50%
	56	55%
	57	60%
	58	65%
	59	70%
	60	75%
	61	80%
	62	85%
	63	90%
	64	95%
	65 and older	100%

 

The percentage not paid by the Bank shall be paid by the Participant via deduction from his or her pension checks (if collecting
pension benefits), a check sent to Astoria Bank HR Health & Welfare Dept., or electronic bill payment

 

    	 	2	 

     

    

 

If any other insurance option is selected
from medical, dental, or vision plans offered by the Bank that is more expensive than the applicable Standard Plan as indicated
on Exhibit B, the Bank will pay 30% of the cost difference between the two options multiplied by the above percentage.

 

Death of an Eligible Officer Prior to Retirement

 

If a Participant dies prior to his or her
retirement from the Bank, such Participant’s spouse at the time of death shall be eligible for coverage with the Bank paying
for 100% of the cost of coverage based on the plans covering the spouse at the time of the Participant’s death or similar
plans selected from future plans offered. Coverage shall remain in effect until such spouse dies or remarries. Dependents of such
Participant and such spouse shall be covered to the extent provided in the applicable plan elected by such spouse in accordance
with this Plan.

 

Examples of the calculation of the cost
of coverage:

 

The examples set forth below illustrate
the methodology in calculating the Participant’s portion of the total cost of coverage and are for illustration only. The
actual cost to the Participant may differ from the examples depending on the total cost for coverage for the underlying medical,
dental or vision plan.

 

Examples (Retirement Before Age 65)

 

		1)	Participant retires at age 62 and selects standard medical and dental options:

 

	
         Monthly
Cost
	 	
        Bank
        Cost
	
        Participant’s

Cost

	 	 	 	 
	$600.00 x .85	=	$510.00	$90.00

 

		2)	Participant chooses the more expensive medical and dental options, $900.00 per month.

 

	
         Standard
Cost
	 	
        Supplement
	 	
        Bank
        Cost
	
        Participant’s

Cost

	 	 	 	 	 	 
	$510.00	+	(.30 x 300 x .85)	=	$586.50	$313.50

 

		*	30%—Additional cost paid by the Bank.

$300—Difference between standard options and the higher options.

85%—Early retirement percentage from the chart.

 

Examples (Retirement On or After Age 65)

 

		1)	Participant selects the standard medical and dental options. Bank pays the full monthly cost of $600.00.

 

		2)	Participant chooses the more expensive medical and dental options, $900 per month.

 

    	 	3	 

     

    

 

	
         Standard
Cost
	 	
        Supplement
	 	
        Bank
        Cost
	
        Participant’s
        

Cost

	 	 	 	 	 	 
	$600.00	+	(.30 x 300)	=	$690.00	$210.00

 

Administration.

 

The Bank is administrator of the Plan (the
“Plan Administrator”). The Plan Administrator may delegate some or all of its duties and authority as such to
one or more employees, to a committee of employees, to a third-party claims administrator or such other persons as the Plan Administrator
deems appropriate. The Plan Administrator may delegate duties and authority with respect to the different coverages under this
Plan to different persons.

 

The Plan Administrator will have the powers
and responsibilities ascribed thereto under this Plan and all the powers necessary or appropriate to carry out its duties, including
the discretionary authority to interpret the provisions of the Plan and the facts and circumstances of claims for benefits, and
to decide questions of fact related thereto. Any interpretation or construction of or action by the Plan Administrator with respect
to the Plan and its administration will be conclusive and binding upon all parties and persons affected hereby.

 

Notwithstanding any Plan provision to the
contrary, no assets will be segregated for the purposes of providing benefits under this Plan unless a separate trust has been
established therefor. Benefits under this Plan will be paid out of the Bank’s general assets, to the extent such benefits
are not paid under the terms of insurance contracts.

 

Claims.

 

Claims will be evaluated by the Plan Administrator
or such other person or entity specified in the documents for a particular coverage, and will be approved or denied in accordance
with the terms of such documents. The claims procedures in the Cafeteria Plan Document of Astoria Bank will apply to the extent
that the procedures under any such documents fail to comply with applicable law. The claim and appeal rules will be construed and
applied in a manner consistent with applicable federal regulations as in effect on the date the claim was received.

 

Amendment and Termination

 

This Plan as amended and restated shall
be effective as of February 22, 2017. Prior to a Change in Control, this Plan may be amended, terminated, modified, or supplemented
by the Bank in its discretion. Following a Change in Control, this Plan may be amended, terminated, modified, or supplemented by
the Bank in its discretion only (a) as required by applicable law (and in the case of any such required amendment, in a manner
that preserves the value of the benefits to any Participant and any Eligible Officer who may be entitled to benefits hereunder)
or (b) with the written consent of each Participant and Eligible Officer who may become entitled to benefits hereunder (taking
into account the limitations on eligibility following a Change of Control as set forth herein); provided that an amendment
or modification to an underlying policy or plan shall not require written consent where each Standard Plan continues to have substantially
similar benefits as those that were available under each such Standard Plan immediately prior to such amendment or modification.

 

    	 	4	 

     

    

 

Exhibit A

Election Form

 

(attached)

 

    	 	A-1	 

     

    

 

 

		
        SENIOR OFFICERS’ RETIREMENT MEDICAL,
        DENTAL & VISION 

POLICY

        ELECTION\DEFERRAL FORM PRE-65

 Retiree
Personal Information

	Full Name:	 	 	 
	 	Last	First	M.I.

 

	Address:	 	 
	 	Street Address	Apartment/Unit #

 

	 	 	 	 
	 	City	State	ZIP Code

 

	Home Phone:	 	Alternate

 Phone:	 	Home

Email:	 

 

	Date of Birth:	 	SSN:	 	Marital

Status:	 

 

 

Check the box for the Plan and coverage level you are selecting
or check the defer enrollment box if you are not enrolling in benefits at this time

 

 MEDICAL
PLAN OPTIONS

	PLAN	RETIREE ONLY	RETIREE & ONE	RETIREE & FAMILY
	CIGNA Health Savings Medical Plan (HSA)	 	 	 
	CIGNA Managed Network Plan	 	 	 
	CIGNA Open Access Plan	 	 	 

 

 DENTAL
PLAN OPTIONS

	PLAN	RETIREE ONLY	RETIREE & ONE	RETIREE & FAMILY
	MetLife Dental DMO	 	 	 
	MetLife Dental PPO	 	 	 

 

 VISION

	PLAN	RETIREE ONLY	RETIREE & ONE	RETIREE & FAMILY
	EyeMed	 	 	 

 

COVERED
DEPENDENTS

	Complete all dependent information and check boxes for selected plans
	RELATIONSHIP	NAME	SSN	DATE OF BIRTH	MEDICAL	DENTAL	VISION
	SPOUSE	 	 	 	 	 	 
	CHILD	 	 	 	 	 	 
	CHILD	 	 	 	 	 	 

 

    	 	A-2	 

     

    

 

ELECTION
TO DEFER ENROLLMENT

	 
	 	
        I elect to defer my enrollment into the Retirement
        Medical, Dental & Vision Policy for Senior Officers at this time.

        I understand that I may elect to enroll in the benefits
        provided under this policy at a later date. I acknowledge that the % of

        cost that the company pays for the Standard Plans
        on Exhibit B of the Policy remains constant, as it is based on my age

        at retirement.

 

 ACKNOWLEDGEMENT

	 
	 	
        I understand that the current cost of each option
        is outlined on the attached personalized spreadsheet.

        I recognize that the offered plans and cost of future
        plans may change. I acknowledge that the % of cost that the company

        pays for the Standard Plans on Exhibit B of the Policy
        remains constant, as it is based on my age at retirement. I further acknowledge that if I elect a plan other than a Standard Plan,
        the company will also pay 30% of the cost difference between the two options multiplied by the Retirement Age associated percentage.

 

	Retiree’s Signature:	 	
        Date:
	 
	
         

        Human Resource

Representative

Signature:
	 	Date:	 

 

    	 	A-3	 

     

    

 

		
        SENIOR OFFICERS’ RETIREMENT MEDICAL,
        DENTAL & VISION 

POLICY

        ELECTION\DEFERRAL FORM AGE 65 OR OVER

Retiree
Personal Information

	Full Name:	 	 	 
	 	Last	First	M.I.

 

	Address:	 	 
	 	Street Address	Apartment/Unit #

 

	 	 	 	 
	 	City	State	ZIP Code

 

	Home Phone:	 	Alternate

 Phone:	 	Home

Email:	 

 

	Date of Birth:	 	SSN:	 	Marital

Status:	 

 

Check the box for the Plan and coverage level you are selecting
or check the defer enrollment box if you are not enrolling in benefits at this time

 

MEDICAL
PLAN OPTIONS

	PLAN	RETIREE ONLY	RETIREE & ONE
	Aetna Medicare Advantage (includes Prescription Drug coverage)	 	 
	United HealthCare AARP with PDP	 	 
	United HealthCare without PDP	 	 

 

DENTAL
PLAN OPTIONS

	PLAN	RETIREE ONLY	RETIREE & ONE
	MetLife Dental DMO	 	 
	MetLife Dental PPO	 	 

 

VISION

	PLAN	RETIREE ONLY	RETIREE & ONE
	EyeMed	 	 

 

COVERED
DEPENDENTS

	Complete all dependent information and check boxes for selected plans
	RELATIONSHIP	NAME	SSN	DATE OF

 BIRTH	MEDICAL	DENTAL	VISION
	SPOUSE	 	 	 	 	 	 

 

ELECTION
TO DEFER ENROLLMENT

	 
	 	
        I elect to defer my enrollment into the
        Retirement Medical, Dental & Vision Policy for Senior Officers at this time.

        I understand that I may elect to enroll
        in the benefits provided under this policy at a later date. 

 

    	 	A-4	 

     

    

 

ACKNOWLEDGEMENT

	 
	 	
        I understand that
        the current cost of each option is outlined on the attached personalized spreadsheet. I recognize that the offered plans and
        cost of future plans may change. I further acknowledge that if I elect a plan other than a Standard Plan, the company
        will also pay 30% of the cost difference between the two options multiplied by the Retirement Age associated percentage.

 

	Retiree’s Signature:	 	
        Date:
	 
	
         

        Human Resource

 Representative Signature :
	 	Date:	 

 

    	 	A-5	 

     

    

 

Exhibit B

Standard Plans

 

This list
may be modfieid or amended in accordance with the amendment provisions of the Amended and Restated Retirement Medical and Dental
Benefit Policy for Senior Officers (Corporate Vice Presidents & Above)

 

Pre-65 Medical Plans

 

CIGNA Managed Network Plan

CIGNA Health Savings Medical Plan (HSA)

 

Calculation of cost for a more expensive plan is based on cost
of CIGNA Managed Network Plan.

 

65 or Older Medical Plans

 

Aetna Medicare Advantage (includes Prescription Drug Coverage
(PDP))

United HealthCare AARP with PDP

United HealthCare without PDP

 

Participants enrolling in a medical plan with a separate PDP
may not elect the PDP as a standalone plan.

 

Dental

 

MetLife - Dental DMO

 

Vision

 

EyeMed Vision

 

    	 	B-1

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