2017 ITHACA HOURLY PRE-MEDICARE RETIREE BENEFIT ELECTION FORM

PERSONAL INFORMATION Retiree Name (Last Name, First Name, Middle Initial): Date of Hire:

Social Security Number: Date of Birth: Date of Retirement:

Home Street Address/Apt.#: City/State/Zip: Home Phone (including area code):

HEALTH INSURANCE Pre-Medicare Medical Plan Election Pre-Medicare rates are a % of the premium based on the retiree’s age as of 01/01/2011 (see below). □ I elect medical coverage in the following Pre-Medicare plan: Premiums are calculated on a per member basis. Choice Health Fund Age of retiree as of 01/01/2011 ______□ Employee only PPO Monthly Premium $1,035_ □ Employee + family CHF Monthly Premium __$700_ Cigna Medical PPO X % Contribution ______□ Employee only X Number Covered ______□ Employee + family = Total Monthly Premium ______□ I decline medical coverage Retirees and dependents must enroll in Medicare Part A and Part B when they become eligible for Dental/Vision Plan Election Medicare – either at age 65 or when disabled. Please Cobra information for dental/vision coverage will be mailed to the home address contact Medicare (1-800-Medicare) for further information. REGISTER OF ELIGIBLE DEPENDENTS UNDER HEALTH INSURANCE PLANS Name Social Security Date of Birth (Last Name, First Name, Middle Initial) Number (00/00/0000) Spouse Add Delete Child Add Delete Child Add Delete I understand that my eligible dependents will be covered under the Plans I elected above. (Children who are not full-time students are eligible dependents until their 19th birthday. Children who are full-time students are eligible until their 25th birthday. Proof of full time enrollment must be provided each semester until age 25.)

I hereby elect the insurance coverage(s) I have designated above. If I have declined any plans, I certify that those plans have been explained to me and I do not wish to participate in them. I understand that adjustments to contributions, deductibles, copayments, and stop-loss provisions are determined on an annual basis and that BorgWarner has the right to modify, suspend, or terminate the insurance I have elected in whole or in part at any time. I understand that this election can only be changed in accordance with the group policies. I agree to pay the monthly premium by the first of each month to the vendor chosen by BorgWarner Inc for that purpose. This choice remains in effect until revoked in writing by me. Failure to pay the premium within 30 days of the due date can result in termination of coverage.

Signature Date

Retiree Premium Cost Share Retiree Premium Cost Share Age as of 01/01/2011 Age as of 01/01/2011 Percentage Percentage 60 and up 10% 54 40% 59 15% 53 45% 58 20% 52 50% 57 25% 51 55% 56 30% 50 60% 55 35% 40-49 100%