SmartCareSM is a Service Mark of John Hancock Life Insurance Company (U.S.A.) and is used under license by John Hancock Life Insurance Company of New York.Both John Hancock Life Insurance Company (U.S.A.) and John Hancock Life Insurance Company of New York do business under certain instances using the John Hancock Retirement Plan Servicesname. Group annuity contracts and recordkeeping agreements are issued by: John Hancock Life Insurance Company (U.S.A.), Boston, MA 02210 (not licensed in New York) and John Hancock LifeInsurance Company of New York, Valhalla, NY 10595. Product features and availability may differ by state. Plan administrative services may be provided by John Hancock Retirement Plan Services LLCor a plan consultant selected by the Plan.

GP1003US (07/2015)

Plan Consultant (TPA) Change Request

2 Current TPA Firm Information - To locate your current TPA Firm/TPA Firm ID, visit the Contact Information section of the Plan Sponsor website

1 General Information

The Trustee ofContractholder Name Contract Number

Name of current TPA Firm

3 New TPA Firm Information

Name of new TPA Firm

TPA Firm Contact Name

Complete this section if you wish to replace TPA Firm named above by the following TPA Firm for the above contract. Unless otherwisedirected, the new TPA Firm listed below will be granted the same website access privileges that are currently in place for your contract, withthe exception of TPA Firm Signing Authority access previously directed by the Plan. Discuss with your new TPA Firm our John HancockRetirement Plan Services Plan Consultant (TPA) Firm Signing Authority Program to confirm their participation and for completion of thenecessary paperwork. If you and your TPA Firm (named in Section 2 above) had previously elected our SmartCare Service, please note that the replacement of yourTPA Firm will result in the termination of the SmartCare Service and the Plan’s participation in the John Hancock Plan Consultant (TPA) FirmSigning Authority Program. The terms and conditions relating to the termination of SmartCare Service are set forth in Section 4 below.To review the current access privilege assigned visit the Plan Sponsor website www.jhpensions.com (in New York,www.jhnypensions.com) under the Contact Information section.

Effective date of change

Effective date can be a future date only. If left blank, effective date will be the datethe form is received by John Hancock Retirement Plan Services.

Address of new TPA Firm - Street Address, City, State, Zip Code (The TPA Firm address information provided will be used to properly identify the TPA Firm on our records.If a TPA Firm address change is required, the TPA Firm contact at the TPA Firm will submit an authorized request to update the Firm's address information)

Fax NumberPhone Number

Month Day Year

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Plan (the “Plan”)

TPA Firm ID

TPA Firm ID

• Your request on this form may result in modifications to your current Contract charges, the Fund Class and/or the annualized Creditsavailable under your Contract. If such modifications apply, you will be provided with information about the updated Contract Charges,Fund Class, and/or annualized Credits prior to the issuance of your Contract. If a Contract has already been issued and this request resultsin a modification to your Fund Class, additional authorization from the Trustee/Authorized Named Fiduciary is required. If this requestresults in a modification to your Contract charges as a result of changes to the annualized Credits available under your contract, you willbe provided with information about the updated annualized Credits. Such changes may also impact your 404a-5 disclosures.

Fax the completed form to our toll free number 1-866-377-9577

The change(s) requested in this form may impact information previously disclosed to your eligible employees. Any changes to previouslydisclosed plan related information will require advance notification to your eligible employees, participants and beneficiaries underERISA Reg. Section 2550.404a-5 at least 30 days in advance of the effective date of the change.

• It is your responsibility to provide such disclosures.

An IRS Form W-9 must be submitted along with this form. Failure to return this form will result in a delay to the changerequested until John Hancock Retirement Plan Services receives the required information.

SmartCareSM is a Service Mark of John Hancock Life Insurance Company (U.S.A.) and is used under license by John Hancock Life Insurance Company of New York.Both John Hancock Life Insurance Company (U.S.A.) and John Hancock Life Insurance Company of New York do business under certain instances using the John Hancock Retirement Plan Servicesname. Group annuity contracts and recordkeeping agreements are issued by: John Hancock Life Insurance Company (U.S.A.), Boston, MA 02210 (not licensed in New York) and John Hancock LifeInsurance Company of New York, Valhalla, NY 10595. Product features and availability may differ by state. Plan administrative services may be provided by John Hancock Retirement Plan Services LLCor a plan consultant selected by the Plan.

GP1003US (07/2015)

Select a Fee Option

No Fees (current TPA Firm fee(s) schedule should be removed and no new fees apply)

New/Change Fees (Complete Section 6 below )

Note: If the above is left blank, the fee(s) that applies to the current TPA Firm noted in Section 2 above will be applied to the new TPA Firm.Accordingly, the same TPA-related plan-level administrative expenses will continue to be deducted from the participant accounts and will bereflected in the 404a-5 Notice. In addition, the same TPA standing loan fee will be applied to participants’ loan requests. However, in orderto have the TPA Firm Standing Loan Fee or any other TPA-related individual expenses reflected in the 404a-5 Notice, your new TPA will haveto provide the details by using the 404a-5 Supplemental Information Tool. If you have restricted your TPA access to this tool, the fee detailswill remain the same and it is your responsibility to ensure this information is kept up to date at all times.

Fees5

TPA Service and Standing Loan Fees 6As Trustee(s) of the Plan named above (“The Plan”), I hereby direct and authorize John Hancock Retirement Plan Services to pay thefollowing TPA fees to the new TPA Firm named above. Any fees entered in A and B below (i.e., annualized TPA Firm Charge and perparticipant fees) will be used to automatically update the 404a-5 Notice for your Plan. However, if you wish to include the TPA Firm standingloan fee or any other in the 404a-5 Notice, your new TPA will have to provide the details by using the 404a-5 Supplemental InformationTool. If you have restricted your TPA access to this tool, the fee details will remain the same and it is your responsibility to ensure thisinformation is kept up to date at all times.

Check the applicable box(es) below:

A Total Annualized TPA Firm Charge of

B * A charge per participant per month

C * A TPA Firm standing loan fee in the amount of (to a maximum of $250.00) for each loan issued under the

contract. This fee will be deducted after the loan amount is deducted

* Does not apply to Defined Benefit Contracts.

%

$

$

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SmartCareSM4Only review and complete Section 4 if you have previously elected the SmartCare Service.In requesting a change of your designated TPA Firm, you and your TPA Firm (named in Section 2) will no longer be using our SmartCareservice. If you wish to continue the use of SmartCare Services with your new TPA Firm (named in Section 3), you and your designated TPAFirm must complete and submit the SmartCare Service Request form. Consult with your TPA Firm to ensure that services required by thePlan are not interrupted.

Terms and Conditions of the termination of SmartCare Service:1. Removal of the service does not automatically change any service agreements made between you and your designated TPA Firm. You are

responsible for notifying your current TPA Firm of the removal of this service.2. Removal of the SmartCare service does not automatically remove online services offered by John Hancock Retirement Plan Services.

Online services will be offered on the same basis as available with SmartCare Service. To modify your online service selections after theremoval of the SmartCare Service, provide John Hancock Retirement Plan Services with an authorized Contract Service Features ChangeRequest form. Up-to-date plan information, regular payroll submissions and full and complete census data files on an ongoing basiscontinue to be requirements of many of these services.

3. Your newly designated TPA Firm (Section 3) will have website privileges to send contributions and employee census files (including yourcontract's cash account and updating census information online). These privileges can be removed or modified at any time by accessingthe Plan Sponsor website or submitting an Authorization of Plan Consultant (TPA) Firm Access Privileges on the TPA Firm Website form.

4. If you and your TPA Firm (Section 3) wish to participate in the John Hancock Retirement Plan Services TPA Signing Authority Program butdo not wish to use the SmartCare Service, you must submit a completed Plan Consultant (TPA) Firm Signing Authority Delegation form.

5. If the SmartCare service is to be used with the new TPA Firm (Section 3) the SmartCare Service Request Form must be completed. TheSmartCare Service will be enabled only upon receipt of the necessary forms.

I, the undersigned Trustee/Authorized Named Fiduciary, hereby acknowledge the Terms and Conditions described above.

SmartCareSM is a Service Mark of John Hancock Life Insurance Company (U.S.A.) and is used under license by John Hancock Life Insurance Company of New York.Both John Hancock Life Insurance Company (U.S.A.) and John Hancock Life Insurance Company of New York do business under certain instances using the John Hancock Retirement Plan Servicesname. Group annuity contracts and recordkeeping agreements are issued by: John Hancock Life Insurance Company (U.S.A.), Boston, MA 02210 (not licensed in New York) and John Hancock LifeInsurance Company of New York, Valhalla, NY 10595. Product features and availability may differ by state. Plan administrative services may be provided by John Hancock Retirement Plan Services LLCor a plan consultant selected by the Plan.

GP1003US (07/2015)

By signing below, I hereby direct John Hancock Retirement PlanServices to make the changes requested above and if applicable, topay to the TPA Firm designated above the referenced fee(s). Iunderstand that the above request shall be processed on theeffective date indicated after this form, properly completed anddeemed to be in ‘good order’ for processing as per John HancockRetirement Plan Services’ current Administrative Guidelines, isreceived by John Hancock Retirement Plan Services. Theauthorization provided herein shall remain effective until writtennotice of change or revocation has been received by John HancockRetirement Plan Services from either the plan trustee, authorizednamed fiduciary or authorized officer of the designated TPA firm. Ifthe authorization is received by the designated TPA firm and theyhave been delegated signing authority, the signing authority will berevoked at the time of notification. The TPA will also no longer beeligible for new payment of fees associated with this contract. Iunderstand that payment of the fee(s) authorized above may bechanged or terminated only upon receipt of written notificationfrom the undersigned or an authorized plan representative.

With respect to the fees authorized above, I acknowledge that thefollowing conditions apply:

1. The effective date of this authorization will be the date that theappointment of the TPA Firm named on page 1 becomeseffective or the date that this form, duly and properly completedis received by John Hancock Retirement Plan Services, whicheveris later.

2. A confirmation of all fees paid will be sent to the TPA Firm andTrustee each month.

3. Service Fees: These fees will be charged from Contract assets (byagreed method described in your Contract) in accordance withinstructions above.

4. Standing Loan Fee:

a. The fee is one time charge for each loan issued under thecontract.

b. The same fee will be applicable to all loans issued within thecontract, unless waived or if John Hancock Retirement PlanServices is otherwise notified.

c. This fee will be paid to the TPA Firm as part of the monthlycharges.

d. This fee will be specified on participant statements.

I understand and agree that these fees will be charged as describedabove and held in John Hancock Retirement Plan Services' generalbusiness account until paid to the TPA Firm. I hereby represent thatthese fees are authorized under the terms of the Plan and that, inmy fiduciary capacity, I have determined that these fees arereasonable. I further certify that the payments to the TPA Firmdesignated above of the TPA Firm service fees and the standingloan fee by John Hancock Retirement Plan Services are notprohibited transactions under the Employee Retirement IncomeSecurity Act or the Internal Revenue Code. I hereby agree toindemnify and hold harmless John Hancock Retirement PlanServices, its affiliates, agents, and employees for any loss, damage,liability, penalty, or tax that such parties may incur if any such

payment is deemed to give rise to one or more such prohibitedtransactions or for implementing the instructions on this form.Unless otherwise directed, the new TPA Firm listed on this form willbe granted the same website access privileges that are currently inplace for my contract, with the exception of TPA Firm SigningAuthority access previously directed by the Plan.

If applicable, I hereby acknowledge that the replacement of theTPA Firm (named in Section 2) will result in the termination of theSmartCare Service and the Plan’s participation in the John HancockRetirement Services Plan Consultant (TPA) Firm Signing AuthorityProgram. I hereby accept and agree to all the Terms and Conditionsdescribed in Section 4. I have discussed with my TPA Firm theremoval of this service and any impacts that this may have on ourservice agreement and/or our respective responsibilities under theplan. I fully understand and acknowledge that failure to performsuch responsibilities may, in some cases, result in administrative oroperational failure for the Plan.

In regards to the termination of the Plan’s participation in the PlanConsultant (TPA) Firm Signing Authority Program, the terminationwill become effective upon initial notification from John HancockRetirement Plan Services that signing authority has been removedfor all TPA Contact(s) with respect to the contract noted above. Iunderstand that the notification will be provided via the MessageCenter on John Hancock Retirement Plan Services Plan Sponsorwebsite. I further understand and agree that until the terminationof this authority becomes effective as described above, the TPAFirm will continue to be able to exercise the privileges previouslygranted, and John Hancock Retirement Plan Services is notresponsible or liable for any action or omission of the TPA Firm.Following the effective date of this termination, the individuals whoare on file with John Hancock Retirement Plan Services as the Plan’sdesignated Authorized Signors (or, if no such individual has beendesignated, the Plan’s Trustee), shall assume the responsibilitypreviously exercised by the TPA Firm pursuant to the privilegesformerly granted.

I further acknowledge that it is my responsibility, and not JohnHancock Retirement Plan Services’, to ensure that all disclosures thatmay be required (including, but not limited to, disclosures requiredunder Department of Labor Regulation Section 2550.404a-5) inconnection with this request, are provided to my eligibleemployees, participants and beneficiaries within the requiredtimelines.On behalf of the Plan Sponsor, the Plan and its related trust, theundersigned Trustee/Authorized Named Fiduciary herebyacknowledges that (i) I, and not John Hancock Retirement PlanServices, am responsible for notifying the current TPA Firm of thetermination of its appointment as the Plan’s designated TPA Firmand such privileges as described above, and (ii) by signing below, Ihereby agree to indemnify and hold harmless John HancockRetirement Plan Services, its affiliates and each of their employees,agents, directors and officers, from and against any and all claims,suits, losses, damages, costs, charges, counsel fees, payments,expenses, and liability arising out of, or attributable to itsimplementation of the instructions contained herein.

7 Authorization

NameSignature of Trustee/Authorized Named Fiduciary Date- please print

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