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HB-0169-0904 STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PENSIONS AND BENEFITS NEW JERSEY STATE HEALTH BENEFITS PROGRAM PO Box 299 Trenton, New Jersey 08625-0299 RESOLUTION A RESOLUTION to terminate participation under the New Jersey State Health Benefits Program (which includes Prescription Drug Program and/or Dental Plan coverage). BE IT RESOLVED: 1. Township of West Orange - Essex Corporate Name of Employer — County hereby resolves to terminate its participation in the program (including Prescription Drug and/or Dental Plan) thereby canceling coverage provided by the New Jersey State Health Benefits Program (N.J.S.A. 52:14-17.25 et seq.) for all its active and retired employees. The We shall notify all active employees of the date of their termination of coverage under the program. We understand that the Division of Pensions and Benefits will notify retired employees of the cancellation of their coverage. We understand that all COBRA participants will be notified by the Division of Pensions and Benefits and advised to contact our office concerning a possible alternative health, prescription drug, and dental insurance program. We understand that this resolution shall take effect the first of the month following a 60-day period beginning with the receipt of the resolution by the State Health Benefits Commission. ! hereby certify that the foregoing is a true and correct copy of a resolution duly adopted by the Township ‘of West Orange Corporate Name of Employer onthe day of. 20. Signature Mayor Official Title 66 Main Street Streel Address West Orange, NJ 07052 Cily Siale Zip Code 973 325-4050 . _ Area Code Telephone # Please complete the reverse side of this form.

HB-0169-0904 PLEASE COMPLETE AND COMPLY WITH THE FOLLOWING: A. Employer New Jersey State Health Benefits Program identification Number B. Type of funding method with the new contract: 1. Conventionally insured fully insured 2. Minimum premium 3. Administrative Services Only (ASO) 4. Other (please list) C. New Health Carrier __ Horizon Blue Cross Blue Shield D. New Prescription Drug Carrier GS POPS E. New Dental Plan Carrier F. Reason for termination of the State Program price G. In accordance with N.J.S.A. 18A:16-21 and 40A:10-25, you must file a copy of your new contract with the State Health Benefits Commission. Please submit a copy of the new contract with this completed resolution.