858-Employe Benefits CooperativBESTflexs'" PLAN ADOPTION AGREEMENT
Group # S196Pic
As set forth below, the following Employer hereby adopts the BESTflexsm Plan (the Plan) and engages EMPLOYEE
BENEFITS COOPERATIVE (EBC), 8309 Greenway Blvd., Middleton, Wisconsin, 53562 (telephone: 608-83 1-8445;
toll free: 800-346-2126), to provide services related to the Plan. The Plan is a "cafeteria plan" as defined in Section
125 of the Internal Revenue Code.
1. EMPLOYER INFORMATION Ocor each related employer, provide same info and how they are related)
Employer Name: City of Sanford
Business Address: 300 N. Park Ave. Sanford, FL. 32771
Street Address: same as above
Nature of Business: Municipality
Name of Contact Persons:(HR) Joe Denaro
Telephone: 407-330-5626
(Payroll) Donna Watt
Fax: 407-330-5606
E-mail Address:
Type of Entity (mark all that apply):
C corp S corp
X
Govt. entity
Sole Proprietorship
Parmership/LLP Church Controlled Non-profit LLC
Other:
Federal Employer Identification Number (EIN): 59-6000425
PLAN INFORMATION
The Plan is (mark one):
An entirely new plan.
X
A continuation (amendment and restatement) of an existing plan that was originally
' established effective on the following date: '10/1/99 and administered most recently by Flex
Comp.
(ATTACH COPY OF MOST RECENT FORM 5500)
The name of the Plan is:
X Cafeteria Plan Document for City of Sanford Flexible Compensation Plan
Other:
The Plan Number (e.g., 501, 502) is: ~'~/
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The Plan records shall be kept on the basis of a 12-month Plan Year ending on:
December 31
X Other: September 30
EFFECTIVE DATE
The Employer adopts the Plan to be effective 10-01-2000 ("Effective Date").
This Agreement shall be in effect for 2 years ("Term") and shall thereafter automatically renew indefinitely
for like Terms, unless terminated earlier as set forth in item 10 below.
PLAN BENEFITS
The following Plan benefits shall be available to eligible employees (check all that apply):
X Group Medical Premiums (Section A of the Plan): Pretax payment of employee premiums
' for coverage under the following plans offered by the Employer (mark all that apply):
X
X Major Medical (insurance, HMO, PPO, self-insured plan, etc.)
X Dental
X Disability Insurance
X Group Term Life Insurance that is:
Stand alone group policy of life insurance
Life Insurance of $ attached to health insurance
X Vision Care
X Cancer Insurance (not a "cash back" policy)
X Accidental Death and Dismemberment Insurance
X Other: Medical Supplement
Health Care FSA (Section B of the Plan) :Pretax payment, by salary reduction and
reimbursement, of qualifying health care expenses incurred by employees.
X Because an employee's annual Health Care FSA election amount is required by law to be
available uniformly throughout the year, the Plan shall limit the amount that an employee
may annually elect to $3,000.00
The Plan shall not limit the annual Health Care FSA election amount.
X Dependent Care FSA (Section C of the Plan): Pretax payment, by salary reduction and
reimbursement, of qualifying dependent care expenses incurred by employees. 5,000.00
Individual Premium Account (Section D of the Plan): Pretax payment, by salary
reduction and reimbursement, of employee premiums for individual billed health related insurance.
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Cash In Lieu of Medical Premiums (Section A of the Plan): Instead of requiring
employees to pay premiums for medical plan coverage, the Employer pays cash as follows to
employees who decline coverage (describe amounts and terms):
EMPLOYER CONTRIBUTIONS
In addition to employee salary reduction contributions, the Employer shall make (mark one):
X
No contributions to the Plan.
Contributions to the Plan as follows (describe amounts and terms):
ELIGIBILITY AND PARTICIPATION
To enroll in the Plan, an employee must timely submit to EBC a properly completed enrollment form for
the applicable Plan Year. An employee must also satisfy the eligibility rules for the various available
benefits as follows ('check one):
All Employees Are eligible (including part time): For Section A of the Plan (Group Medial
Premiums and/or Cash In Lieu of Medical Premiums), an employee must be eligible for coverage under the
terms of the applicable underlying plans. For Sections B, C, and D of the plan (Health Care FSA,
Dependent Care FSA, and/or Individual Premium Account), all employees are eligible, regardless of how
few hours they work.
X
Only Employees Who Work Sufficient Hours Are Eligible: For Section A of the Plan
(Group Medical Premiums and/or Cash In Lieu of Medical Premiums), an employee must be eligible for
coverage under the terms of the applicable underlying plans. For Sections B, C, and/or D of the Plan
(Health Care FSA, Dependent Care FSA, and/or Individual Premium Account), an employee must be
regularly scheduled to work at least:
hours per week
X Other: Regular F/T 30 + hrs. per week: Regular P/T 30 hrs
or less per week
Other Requirements (e.g., class, union) To participate in the Plan, an employee must:
Participation in the Plan Begins (check one):
X First of the month following:
30 days 60 days X 90 days
Other:
From date of hire: 30 days 60 days 90 days 6 months Other:
Date of Hire
Other (describe):
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SERVICES AND FEES OF EMPLOYEE BENEFITS COOPERATIVE
EBC shall provide the following services to the Employer for the following fees:
A,
First Year Set Up Services
First Year Set Up Fee: $ 0.00 * (nonrefundable after EBC begins services, see asterisk in 7C)
Number of eligible employees:
Fee includes:
· Plan document
· Summary Plan Description
· Employee educational and first plan year enrollment materials
· Set up of employee first plan year enrollment information on EBC system
· Nondiscrimination testing (once per year; additional tests at $150 each)
· First year IRS Form 5500 (additional Forms 5500 at $150 each)
· Summary annual report as required by law
Renewal Year Set Up Services
Later Year Set Up Fee: $ 0.00 ** (nonrefundable after EBC begins services for applicable year*)
Number of eligible employees:
Fee includes:
· Plan document revisions (if any)
· Summary Plan Description revisions (if any)
· Employee educational and new year enrollment materials
· Set up of employee new year enrollment information on EBC system
· Nondiscrimination testing (once per year; additional tests at $150 each)
· Annual IRS Form 5500 (one per year; additional Forms 5500 at $150 each)
· Summary annual report as required by law
Monthly Administrative Services
Monthly Service Fee: $0.00*per FSA participant per month (subject to change)
Paid by:
Employer Employee Employer/Employee Split
Fee includes: · Monitoring of employee benefit account reimbursement limits
· Changes to employee account information on EBC system
· Review of benefit claims for payment qualification
· Paying of qualified claims (to me extent the Employer has provided funds)
· Direct deposit of reimbursement
· Periodic reports to Employer
*EBC may upon notice to the Employer increase its fees from year to year by an amount equivalent to the increase
in the Consumer Price Index (All Urban Consumers, U.S. City Average, All Items).
* * Fee subject to change if the number of eligible employees is different than the first year.
D,
Optional Administrative Services (billed separately and subject to change):
1. EBC staff travel over 3 hour drive from Madison (food, lodging, par diem)
2. Employee meetings and/or individual counseling ($55/honr; minimum $165/day)
3. Automated Telephone Enrollment System (ATES) $2.00 per ATES participant
4. Extraordinary one-time services (billed as agreed upon by EBC and the Employer)
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E,
Optional Legal Services (billed separately and subject to change):
1. Legal research or plan documents by EBC ($50/hour; 1 hour minimum)
2. Legal research or plan documents by EBC appointed attorney (per attorney)
F,
Termination (billed separately and subject to change):
If the Employer terminates this Agreement without proper notice to EBC as described in item 10 below or
terminates this Agreement effective before the last day of the initial Term or a renewal Term, then the
Employer shall pay to EBC the standard fee. Currently the fee is $300.
G. Other:
8. RESPONSIBILITIES OF THE EMPLOYER
A. Effect of Agreement: This Agreement, along with the BESTflexsm Plan document and any addenda
attached to the Agreement, contains all the provisions of an Internal Revenue Code § 125 "cafeteria plan" adopted
by the Employer. This Agreement is also a contract between the Employer and EBC. The Employer may wish to
consult its legal counsel before executing this Agreement.
B. Plan Sponsor and Administrator: The Employer is both the sponsor and the administrator of the Plan,
with the ultimate responsibility for: (1) ensuring that the Plan complies with all applicable federal, state, and local
laws, including Internal Revenue Code § 125; (2) establishing, mending, terminating, and interpreting the Plan
provisions; and (3) determining whether particular claims shall be paid. Although the Employer has engaged
EBC to provide certain documents and administrative services (including review and payment of qualified claims
under the Plan), EBC shall whenever possible, consistent with this Agreement, act as directed by the Employer.
C. ERISA: The Employer has determined that the Plan is or is not governed by the Employee Retirement
Income Security Act of 1974 as follows (check one):
The Plan is governed by ERISA.
X The Plan is not governed by ERISA (such as because the Plan is a "governmental plan" or a "church
' plan" or no Health FSA is present).
The Employer cannot determine whether the Plan is governed by ERISA.
D. Funding of Plan: The Employer shall provide EBC with all ftmds that EBC needs to pay benefit claims
under the Plan. IfEBC pays a qualified benefit claim in advance of receipt of the corresponding funds from the
Employer, the Employer shall provide the funds to EBC within 2 days of notice of such payment by EBC.
E. Cooperation with EBC: So that EBC can perform its services regarding the Plan, the Employer shall
timely provide EBC with all information that EBC reasonably requests, including completed employee enrollment
forms, employee census data, and nondiscrimination testing data and otherwise cooperate with EBC.
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10.
INDEMNITY
The Employer shall indemnify EBC, its employees, directors, and agents (collectively, Indemnitees) and hold the
Indemnities harmless against all damages, losses, or other liabilities incurred by the Indemnitees arising from any
act or failure to act by the Employer, its employees, directors, or agents in connection with the Plan. Such
indemnification shall include (and not be limited to) liabilities arising from a failure to timely provide EBC with
information. Such indemnification shall also include liabilities arising from administration or interpretation of the
Plan by the Employer in a manner contrary to law.
TERMINATION
A. Termination At End Of Term After 60 Day Notice. Either party may, upon written notice to the other
party at least sixty days' before the end of the initial Term or of any renewal Term, terminate this Agreement
effective as of such end of Term date.
B. Other Termination By Employer. The Employer may terminate the Agreement effective (1) as of an end
of Term date without the 60-day notice or (2) on a date other than an end-of-Term date. If the Employer does so,
however, the Employer shall pay EBC the termination fee set forth in item 7F above.
C. Other Termination by EBC. EBC may terminate the Agreement effective (1) as of an end of Term date
without the 60 day notice or (2) on a date other than an end of Term date, but only if the Employer previously
breached this Agreement, such as by failing to pay EBC for its services, failing to provide funds for payment of
claims, or failing to cooperate with EBC.
D. Wrap Up Period. If either party terminates the Agreement, EBC shall complete its services that pertain to
the period prior to the effective date of the termination and the Employer shall pay EBC for such services. In
particular, EBC shall review and pay claims for the 90 day period after the final Plan Year (or part thereof) and
the Employer shall pay EBC the Monthly Service Fees described in item 7C above for that period.
The Employer and EBC executed this Adoption Agreement on the dates set forth below.
Tony VanDer~orp'
Date: 10/19/00
Thle: City Manager
EMPLOYEE BENEFITS COOPERATIVE
By: ~~A~ %
Date:
Title: ENROLLMENT COORDINATOR
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