Res 59-02RESOLUTION NO. 59-02
A RESOLUTION OF THE CITY COMMISSION OF THE
CITY OF DELRAY BEACH, FLORIDA, ADOPTING A
CAFETERIA PLAN IN ACCORDANCE WITH SECTION 125
OF THE INTERNAL REVENUE CODE, INCLUDING
DEPENDENT CARE IN ACCORDANCE WITH SECTION
129 OF THE INTERNAL REVENUE CODE AND MEDICAL
REIMBURSEMENT IN ACCORDANCE WITH SECTION 105
OF THE INTERNAL REVENUE CODE; PROVIDING FOR
CONFLICTS; SUPERSEDING AND REPEALING PREVIOUS
PLANS; PROVIDING FOR SEVERABILITY; PROVIDING AN
EFFECTIVE DATE.
WHEREAS, the City Commission wishes to adopt a flexible benefits plan for city employees
that provides a "cafeteria plan" within the meaning of section 125 of the Internal Revenue Code,
including dependent care as provided in section 129 of the Internal Revenue Code, and medical
reimbursement as provided in section 105 of the Internal Revenue Code.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF THE
CITY OF DELRAY BEACH, FLORIDA:
Section 1.
A. That the City adopt a Flexible Benefits Plan known as a cafeteria plan under section 125
of the Internal Revenue Code, including a dependent care selection as provided by section 129 of
the Internal Revenue Code, and a medical care expense reimbursement as provided by section 105
of the Internal Revenue Code.
B. That the Flexible Benefits Plan be that attached hereto.
C. That the adoption extends to the plan adoption agreement and policies also attached
hereto.
D. That the City through its authorized officials execute such documents as may be
necessary to implement the plan.
E. That the City may amend the plan from time to time by resolution as may be necessary
or appropriate.
Section 2. That this resolution shall supersede any and all conflicting provisions of any
previously adopted resolutions.
Section 3. That the Flexible Benefits Plan adopted herein shall supersede any such
similar or equivalent plan previously adopted, and that any and all such similar or equivalent plans
are hereby repealed.
Section 4. That should any section or provision of this resolution or any portion
thereof, any paragraph, sentence, or word be declared by a court of competent jurisdiction to be
invalid, such decision shall not affect the validity of the remainder hereof as a whole or part thereof
other than the part declared to be invalid.
Section 5. That this resolution shall take effect on ~'-~/ ~x,ta~ ,2002.
PASSED and ADOtrFED this ca'l° day of ~' ,2002.
MAYOR
ATTEST:
City Clerk
2 RES. NO. 59-02
n
MEMORANDUM
To:
From:
Date:
David T. Harden, City Manager
Joseph M. SaUce Director
Il
June 27, 2002
Subject:
Submission of Flexible Benefits Plan for Employees
This office presented correspondence to your office dated April l0th regarding a package
of voluntary benefits to be presented to employees. Part of this benefit package includes
pre-tax benefits which have to be incorporated into a Section 125 Flexible Benefits Plan
document and passed, in resolution form, by the City Commission.
The attached memorandum dated April 10, 2002 provides a full explanation of all the
voluntary benefits to be offered to our employees. In summary, these benefits include:
· Group medical insurance plan for dependents
· Group dental/vision insurance plan for employee and dependents
· Personal cancer care protection insurance
· Personal heart and stroke care protection insurance
· Personal hospital and confinement protection insurance
· Personal accident expense protection insurance
· Medical flexible spending account
· Dependent care flexible spending account
· Whole life and term insurance protection
· Section 529 higher education savings plan
· ICMA VantageCare retiree health savings plan
· Personal financial planning services
The Section 125 Flexible Benefits Plan Resolution (No. 59-02), as drafted by the City
Attorney, is attached and is requested to be submitted to the City Commission for
approval. This plan will include any benefits that are elected by the employee on a pre-
tax basis. All post-tax benefits are not included in the Section 125 plan
We would request approval of Resolution No. 59-02.
RESOLUTION NO. 59-02
A RESOLUTION OF THE CITY COMMISSION OF THE CITY OF
DELRAY BEACH, FLORIDA, ADOPTING A CAFETERIA PLAN IN
ACCORDANCE WITH SECTION 125 OF THE INTERNAL
REVENUE CODE, INCLUDING DEPENDENT CARE IN
ACCORDANCE WITH SECTION 129 OF THE INTERNAL
REVENUE CODE AND MEDICAL REIMBURSEMENT IN
ACCORDANCE WITH SECTION 105 OF THE INTERNAL
REVENUE CODE; PROVIDING FOR CONFLICTS; SUPERSEDING
AND REPEALING PREVIOUS PLANS; PROVIDING FOR
SEVERABILITY; PROVIDING AN EFFECTIVE DATE.
WHEREAS, the City Commission wishes to adopt a flexible benefits plan for city~
employees that provides a "cafeteria plan" within the meaning of section 125 of the Internal
Revenue Code, including dependent care as provided in section 129 of the Internal Revenue
Code, and medical reimbursement as provided in section 105 of the Internal Revenue Code.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF THE CITY OF
DELRAY BEACH, FLORIDA:
Section 1.
A. That the City adopt a Flexible Benefits Plan known as a cafeteria plan under section
125 of the Internal Revenue Code, including a dependent care selection as provided by section
129 of the Internal Revenue Code, and a medical care expense reimbursement as provided by
section 105 of the Internal Revenue Code.
C.
hereto.
That the Flexible Benefits Plan be that attached hereto.
That the adoption extends to the plan adoption agreement and policies also attached
D. That the City through its authorized officials execute such documents as may be.
necessary to implement the plan.
E. That the City may amend the plan from time to time by resolution as may be necessary
or appropriate.
Section 2. That this resolution shall supersede any and all conflicting provisions of any
previously adopted resolutions.
Section 3. That the Flexible Benefits Plan adopted herein shall supersede any such
similar or equivalent plan previously adopted, and that any and all such similar or equivalent
plans are hereby repealed.
Section 4. That should any section or provision of this resolution or any portion thereof,
any paragraph, sentence, or word be declared by a court of competent jurisdiction to be invalid,
such decision shall not affect the validity of the remainder hereof as a whole or part thereof other
than the part declared to be invalid.
Section 5. That this resolution shall take effect on. ,2002.
PASSED and ADOPTED this ~ day of ,2002.
ATTEST:
MAYOR
CITY CLERK
2
RES. NO. 59-02
, Appendix to Resolution No. 59-02
REIMBURSEMENT SERVICES AGREEMENT
This Agreement, effective upon executIon for the Plan Year, by and between
CITY OF DELRAY BEACH
and American Family Life Assurance Company ("AFLACe'')
WITNESSETH:
WHEREAS, the Employer has adopted a Medical Care Expense Reimbursement ("URM") Plan and/or a
Dependent Care Expense Reimbursement ("DDC") Plan for its Employees in conjunction with its
Flexible Benefits Plan (collectively referred to as the "Plan" and attached hereto) to be adopted and
administered in accordance with Sections 105, 125, and 129 of the internal Revenue Code of 1986, as
amended (the "Code"); and
WHEREAS, the Employer will serve as the Plan Administrator; and
WHEREAS, the Employer desires that AFl_AC, as its agent, furnish reimbursement services within a
framework of policies, interpretations, rules, practices and procedures (the "reimbursement practices and
procedures") made and established by the Employer in: (i) receiving and processing requests for
benefits under the Plan ("Requests") and (ii) disbursing benefit payments from Employer funds (as
provided for in Section II.A.) for eligible expenses under the flexible spending account provisions of the
Plan, (if Self-Pay Option is selected in Section II.A. below, AFLAC shall convey its initial benefit
determinations to Employer so the Employer can disburse reimbursement payments for eligible
expenses under the Flexible Spending Agreement provisions of the Plan); and
WHEREAS, the Employer is to pay all plan benefits owed or established under the Plan to its
Participants, and AFLAC is to provide the agreed upon services to the PLan without assuming any such
liability;
NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, it is
hereby agreed as follows:
Section I. Enrollment and,..Determination of Elicjlibility
A. The Employer shall:
(1) be responsible for interpreting the Plan and its provisions, its terms, conditions and operation;
and
(2) notify Plan Participants of their ability to apply for reimbursement benefits and supply them with
Request forms (to be provided by AFl_AC) and Request filing instructions; and
(3) provide AFl_AC with the names, addresses, Social Security Numbers, and elected amounts of
all participants in the Plan; and
(4) upon the occurrence of events that would change a Participant's status under the Plan (e.g.
termination, Change in Status, Change in Cost or Coverage for DDC, etc.) immediately provide
AFLAC with updates (via Telefax) which identify eligible Participants in each of the respective
reimbursement Plans and/or the amount of reimbursement benefits for which they are eligible,
and
(5) immediately inform AFl_AC (via Telefax) as to any new Participants in either of the
reimbursement Plans, any Change in Status affecting a Participant's election, or any Qualified
Beneficiary electing coverage under COBRA and the amount of such election (if COBRA applies
to the Employer), or of any other change which will affect AFLAC's responsibilities hereunder.
B. In determining any person's right to benefits under the Plan, AFLAC shall rely on the eligibility
information furnished by the Employer, and any signed statements by Participants regarding the
eligibihty of their Requests under the respective Plan. It is mutually understood that the effective
performance of this Agreement by AFLAC will require that it be advised on a timely basis by the
Employer during the continuance of this Agreement of the identity of individuals eligible for benefits
under each of the respective reimbursement Plans. Information modifying a Participant's eligibility or
status/election under either reimbursement Plan shall identify the effective date of eligibility and the
termination date of eligibility and shall be provided to AFl_AC (via Telefax) prior to the effective d.ate of
such modification in order to be considered by AFLAC in making benefit determinations hereunder.
AFLAC shall not be responsible for Requests paid in error where the Employer has failed to inform
AFLAC (in a form and with such information as may reasonably be required by AFl_AC) of a Participant's
eligibility or status change prior to the release of the benefit payment.
Section II. Fund!n~l and Payment of Requests for the Plan Benefits
A. Select one below:
~'1 Daily Processing Option. The Employer shall:
(i) make sufficient funds available from its general assets for amounts allocable to eligible
reimbursement benefits under its plan by depositing a "Maintenance Deposit" (in amounts
specified by AFl_AC from time to time) in an Employer-owned and named account (the
I 'RSA
(mcludm9 apphcable fees) under which such services are provided are set forth ~n Appendix B
"Nondlscr~minahon Testing and Form 5500 Preparation Services".
(2)
Upon written request submitted to AFLAC's FLEX ONE®Department at the close of each Plan
Year, AFLAC may assist w~th the preparation of Form 5500 for the Plan. Such request must be
made within 120 days after the end of each Plan Year. The terms and conditions (including
apphcable fees) under which services are provided are set forth in Appendix B
"NondiscriminatIon Testing Services and Form 5500 Preparation Services".
In providing services, AFLAC shall assume that ERISA and COBRA apply to the Employer's Plan unless the
Employer gives AFLAC written direction otherwise.
AFLAC shall not be obligated or responsible for any duty with regard to the administrabon of the Plan
(imposed by the Plan or otherwise) except as specifically provided above Employer has carefully
reviewed and agrees to be responsible for the "Plan Sponsor Responsibilities" summarized on the back
of the Plan Document Request (PDR) Form. W~thout limiting Employer's respons~bdibes described
therein, it shall be the Employer's sole responsibility (as Plan Administrator) and duty to: ensure
compliance with COBRA; perform required nondiscrimination testing; amend the Plan as necessary to
ensure ongoing compliance with applicable law; file any required tax or governmental returns (including
Form 5500 returns) relating to the Plan to determine if and when a valid election change has occurred;
handle Participant claim appeals; allow AFl_AC, by and through independent associates, a reasonable
opportunity to discuss AFLAC, URM, and DDC benefits, execute and retain required Plan and claims
documentation; and take all other steps necessary to maintain and operate the Plan in compliance with
applicable provisions of the Plan, ERISA, the Code and other applicable Federal and State laws.
In the event that AFLAC overpays any person entitled to benefits under the Plan, or pays benefits to any
person who is not entitled to them, AFLAC shall take all reasonable steps to recover the overpayment
except that AFLAC shall not be required to initiate court proceedings to recover an overpayment.
AFLAC shall promptly notify the Employer if it is unsuccessful in recovering any overpayment.
Bo
AFLAC will optically scan and maintain electronic cop~es of all FSA Reimbursement Requests and
supporting documentabon for a period of seven (7) years after the claim is processed. Copies of FSA
claim documents can be reproduced upon written request at AFLAC's currently prevailing rate.
Section III. Liability and Indemnity
In performing its obligabons under this Agreement, AFLAC neither assumes nor underwrites any liability
of the Employer under the Plan, but with respect to the Employer, acts only as provider of those services
specifically described in Section ll.B. of this Agreement and with respect to Plan Participants, acts only
as the agent of the Employer. The services to be performed by AFLAC shall be ministerial in nature and
shall be performed within the framework of policies, interpretations, rules, practices, and procedures
made or established by the Employer AFLAC shall have no discretionary authority or discretionary
control over any assets of the Employer, the Plan, or Plan Participants.
AFLAC shall have no duty or obligation to defend any legal action or proceeding brought to recover a
Request for Plan Benefits. AFLAC shall, however, make available to the Employer and ~ts counsel, such
evidence relevant to such action or proceeding as AFLAC may have as a result of its processing of the
contested benefit determ,nation.
Co
Except as otherwise explicitly provided in this Agreement, the Employer shall retain the liability for all
Plan Benefit Requests and all expenses incident to the Plan and for any and all wolations of the
Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA"), if applicable, and agrees to
indemnify AFLAC for and hold it, its directors, officers, and employees, harmless from all amounts and
expenses (including reasonable attorneys' fees and court costs) for which AFLAC may become liable.
This indemnity shall survive the termination of this Agreement.
AFLAC shall use ordinary and reasonable care in the performance of its duties, but shall not be liable to
the Employer for mistakes of judgment or other actions taken in good faith unless such error results
directly from an intentionally wrongful or grossly negligent act of AFLAC, its officers or employees.
AFLAC shall have no duty or obligation with respect to Requests incurred prior to the effective date of
this Agreement (hereafter "Prior Reimbursement Requests") and/or Plan Administrator (or other)
services arising prior to the effective date of this Agreement regardless of whether such services
were/are to be pedormed prior to or after the effective date of this Agreement (hereafter "Prior
'Administration"). The Employer specifically acknowledge(s) and agree(s) that: ti) AFLAC has no
responsibility or obligation with respect to Prior Reimbursement Requests and/or Prior Administration;
the Employer will be responsible for processing Prior Reimbursement Requests (including any run-off
Requests submitted after the effective date of this Agreement) and maintaining legally required records
of all Prior Reimbursement Requests and Prior Administration sufficient to comply with applicable legal
(e.g., IRS substantiation) requirements and (iii) the Employer agrees to indemnify and hold AFl_AC
harmless for any I,a..bihty relating to Pnor Reimbursement Requests and/or Prior Administration.
3 ~s~
(4)
At the option of AFLAC, if no Plan Participant is an AFLAC policyholder or if the Employer
denies AFLAC a reasonable opportunity (as determined by AFLAC in ~ts sole d~scretion) to meet
with Employees, AFLAC shall immediately commumcate its elecbon of this option to the
Employer.
(5) Any other date mutually agreeable to the Employer and AFl_AC.
Upon termination of this Agreement, AFLAC shall cease the processing of all Requests then in its
possession, return any undistributed funds to the Employer, and make all records relating to Requests in
process reasonably available to the Employer. If the termination occurs pursuant to VI.AA. (above),
AFLAC shall process all run-off claims provided any Service fee(s) is current. Thereafter, the Employer
and/or Plan Administrator shall be responsible for all aspects of Reimbursement Requests processing
and Plan administration.
Section VII. Miscellaneous
(1)
(2)
(3)
Notices. Any notice required to be given hereunder to AFLAC shall be sufficient if in writing and
delivered personally or by prepaid first class mail to AFLAC Administrative Services/Flex One®,
1932 Wynnton Road, Columbus, GA 31993-9615, or ~f to the Employer, at the address of the
Employer denoted on the signature page attached hereto.
Applicable Law. This Agreement shall be governed by, and shall be construed in accordance
with the laws of the State of Georgia, to the extent they are not preempted by ERISA, the Code,
or any other Federal law.
Legal and Tax Status. The Employer acknowledges that neither AFLAC nor its agents is
providing legal or tax advice, and that neither AFLAO nor its agents serves as the plan
administrator or a plan administrator or a fiduciary under the Plan. The Employer shall be the
sole party responsible for determining the legal and tax status of the Plan under applicable law.
AFLAC shall have no power or authority to waive, alter, breach or modify any terms or
conditions of the Plan.
(4)
(5)
(6)
(7)
Assignment. This Agreement may be assigned by AFLAC to any other party, including any
successor to the business of AFLAC by merger, consolidation, purchase of assets, or otherwise,
without the prior consent of the Employer. This Agreement shall be binding upon any
corporation into which the Employer may be merged or with which it may be consolidated, or
any corporation succeeding to all or substantially all of the business of the Employer.
Entire Contract. This Agreement constitutes the entire contract between the parties and no
modification or amendment hereto shall be valid unless in writing and signed by an officer of the
Employer and an Officer or duly authorized representative of AFLAC.
Tax Reporting and W!th. holdings. The Employer has ultimate control over the payment of
Plan benefits and shall be the sole party responsible for income and employment tax reporting
and withholding obligations imposed as a result of the includabdity of such payments in the
gross income of recipients. AFLAC is a mere agent of the Employer for the processing of
benefit Requests.
Confidential Information. The term "Confidential Information" as used in this Agreement means
confidential or proprietary information of any party that is not generally known to the public,
including, but not limited to compilations, lists of actual or potential customers or suppliers,
hardware systems, software, or other documentation of any type, whether in printed or machine
readable form, computer databases, forms and form letters, contracts, information regarding
specific transaction and marketing and business plans. For the purposes of this subsection,
Confidential Information shall not include the personally idenbfiable information relating to any of
Employer's employees.
The term "Trade Secrets" as used in this Agreement shall mean Confidential Information that:
(1) derives economic value, actual or potential, from not being generally known to, and not being
readily ascertainable by proper means by, other persons who can obtain economic value from
its disclosure or use; and (2) is the subject of efforts that are reasonable under the
circumstances to maintain its secrecy. The terms "Conhdential Information'" and "Trade
Secrets" do not include information that: (a) is known to the receiving party prior to its
disclosure by the disclosing party, as evidenced by the receiving party's writ-ten records; (b) is
developed by the receiving party independently of any of the Confidential Information or Trade
Secrets received m confidence from disclosing party, evidenced by the receiving party's written
records; (c) is rightfully received by the receiving party from a third party without restriction and
without breach of any obligation of confidentiality running to the disclosing party.
, Each party agrees that it shall not disclose to others or use for any purpose other than
'performance of the Agreement any of the other party's Confidential Information or Trade
5
Appendix A
Schedule of Services to Be Provided By AFLAC
In accordance with attached Reimbursement Services Agreement AFLAC shall provide the following
services for the Employer:
General Plan Services:
provide the Employer with a sample cafeteria plan document, including a medical care expense
reimbursement ("URM") Plan and a dependent care expense reimbursement ("DDC") Plan to be
reviewed by the Employer and its legal counsel; and
provide the Employer with a sample flexible benefits summary plan description for distribution to each
Plan Participant and employees and where may be required by a Change in Status; and
upon receiving instructions from the Employer on a Change in Status, AFLAC will make the change
requested by the Employer.
Additional Services if DDC or URM Benefits Are Offered:
assist the Employer in explaining the URM and/or DOC features of the cafeteria plan to employees; and
process for the Employee-executed salary redirection agreements as they relate to the URM and DOC
components of the Employer's flexible spending account; and
prepare an enrollment confirmation letter and send it to the Employer to verify URM and DDC elections;
and
provide each Participant with a URM and/or DDC statement on a quarterly basis; and
provide the Employer with written monthly reports summarizing the previous period's URM and/or DDC
and Account activities; and
receive Requests for URM and/or DDC benefits, and expeditiously review such Requests to determine
what amount, if any, is due and payable with respect thereto; and
disburse the benefit payments it determines to be due (provided the Employer transfers sufficient funds
to AFLAC or has sufficient funds in the Account) or if Self-Pay is elected under Section I1. A., notify the
Employer of the benefit determination in accordance with the provisions of the Plan and the following
procedures:
valid reimbursement for URM and/or DDC benefits shall be paid by AFLAC on the date funds
are received from the Employer (with respect to such Requests) by mailing a check in the
appropriate amount(s) directly to the Participants at their home addresses; and
if the amount of the (otherwise) reimbursable DDC Request exceeds the amount the
Participant had withheld for DDC benefits, the excess shall be carried forward (within the same
Plan Year) and treated as an Eligible Employment Related Expense for that month; and
if the amount of the reimbursable URM Requests exceeds the amount the Participant has had
withheld from URM benefits, the entire amount shall be processed (provided the Employer
makes available sufficient funds for AFl_AC to satisfy the Request); and
Requests of less than $15.00 may be carried forward and aggregated with future Requests' until
the reimbursable amount is greater than $15.00, provided however, that the entire amount of
the reimbursable Requests shall be paid after the close of the Plan Year without regard to the
$15.00 threshold; and
under the Daily Processing Option, checks of $2,000 or more shall be forwarded to the
Employer for countersignature and disbursement; and
unless otherwise specified in writing by the Employer, Health FSA claims following a Change in
Status impacting the Health FSA election shall be processed using a "blended approach" i.e.,
the maximum Health FSA benefit for a period of coverage following a Change in Status will be
limited to the lesser of' a) the annual Health FSA maximum set forth in the Plan document less
any benefit payments made prior to the Change in Status; and b) the sum of the Participant's
Health FSA Account balance immediately before the Change in Status and any additional
contributions made during the remaining period of coverage; and
7 RSA
m
mm ~
m, {~
APPENDIX B
Nondiscrimination Testing Services and Form 5500 Preparation Services
[Provided Upon Annual Request]
Nondiscrimination Testing:
The Employer, upon submission of an annual Employee Census Data Sheet, authorizes AFLAC to compde
nondmcnmination tesbng percentages based upon the employee census data provided As considerabon for th~s
service, the Plan Sponsor/Admimstrator agrees to release and hold AFLAC, its subsidiaries, afflhates, officers,
directors, owners, shareholders, attorneys, successors and assigns harmless from any liabihty arising as a result
of the provision of, or reliance upon such testing percentages. In addibon, the Employer understands and agrees
that:
AFLAC is not in the business of providing legal or tax advice, and the Employer, as the plan
sponsor/administrator, will not construe the testing percentages provided by AFLAC to be legal or tax
advice. Accordingly, the Employer will seek the advice of Ks own tax or legal advisor to interpret and
verify the testing percentages provided, and ensure compliance with applicable nondiscrimination
requirements.
The Employer bears sole responsibility for nondiscrimination testing and the continued qualified status of
its cafeteria plan under all applicable provisions of the Internal Revenue Code.
The testing percentages provided by AFLAC are merely an indicator of compliance with two of the
applicable nondiscrimination tests - the Cafeteria Plan 25% Key Employee Concentrat,on Test and the
Dependent Care 55% Average Benefits Test Each Employer must also ensure compliance with the
Eligibility Test and Contribubons and Benefits Test applicable to the Cafeteria Plan, the URM, and the
DDC Plan, as well as other tests that may apply to the benefits offered through the Cafeteria Plan. To
ensure compliance with applicable provisions of the Internal Revenue Code, additional nondiscrimination
testing and result verificabon must be undertaken by the Employer with the assistance of its tax or legal
counsel.
Discrimination testing should be conducted at least 180 days prior to the end of the Plan Year to which
the data relates to ensure adequate time to make any required corrections. AFLAC will assist with
discrimination tesbng no less frequently than once per year and no more frequently than once every
thirty (30) days.
Form 5500 Preparation:
The Employer, upon submission of an annual Request for Form 5500 Filing Assistance, Plan Sponsor and
Cafeteria Plan Information Data Sheet, authorizes AFLAC to prepare a sample Form 5500 and applicable
schedules based upon the information it provides regarding the company and its cafeteria plan. In consideration
for this service, the Employer agrees to release and hold AFl_AC, ~ts predecessors, representatives, agents,
associates, employees, parent companies, subsidiaries, affiliates, officers, d~rectors, owners, shareholders,
attorneys, successors, and assigns, harmless from any liability arising as a result of the provision of, or reliance
upon such sample forms. In addition, the Employer understands and agrees that.
AFLAC is not in the business of providing legal or tax advice, and Employer will not construe the
completed sample 5500 forms to be legal or tax advice. Accordingly, the Employer should seek the
advice of its own tax or legal advisor to verify that the form was properly completed and all required
information included, and ensure compliance with all applicable regulations and requirements.
The Employer bears sole responsibility for submitting the Form 5500 and all applicable schedules and
the continued qualified status of its cafeteria plan under all applicable provisions of the Internal Revenue
Code.
The completed 5500 and attached schedules are provided by AFLAC, upon request, for active
FLEX ONE®accounts, merely as a service to help fulfill the filing requirements set forth by Section
6039D of the Internal Revenue Code for cafeteria plans. To ensure compliance with the applicable
provisions of the Internal Revenue Code and ERISA guidelines, additional informabon or filings may be
required as it pertains to other welfare benefit plans sponsored by the Employer/Plan Sponsor.
Providing AFLAC with the reformation needed to complete the Form 5500 does not constitute an actual
filing with the Internal Revenue Service. The timely submission of the appropriate forms remains the
responsibility of the Employer.
If AFL.AC has been asked to prepare sample Form 5500s after the filing deadline has passed, the
Employer agrees to release and hold AFLAC, its predecessors, representatives, agents, associates,
employees, parent companies, subsidiaries, affiliates, officers, directors, owners, shareholders, attorneys,
successors, and assigns, harmless from any liability arising as a result of the late filing of the forms.
9 RSA
· FLEXIBLE BENEFITS PLAN SUMMARY PLAN DESCRIPTION FOR:
CITY OF DELRAY BEACH
FLEXIBLE BENEFITS PLAN
EMPLOYER INFORMATION
1) Name and Address of Employer/
CITY OF DELRAY BEACH
Plan Administrator:
2) Employer's Telephone Number:
3) Employer's Federal Tax 113 Number:
4) Plan Number Assigned to Cafeteria
Plan (e.g., 501 if this is the first ERISA
plan number assigned):
5) 125 Start Date:
6) Effective Date of the Plan:
7) Last [3ay of the Plan Year:
Subsequent Plan Years:
8) Name and Address of the
Plan Service Prowder:
9)
10)
Name and Title of Registered Agent
for Service of Legal Process:
JOSEPH SAFFORD
100 NW 1ST AVE
DELRAY BEACH, FL 33444
(561) 243-7116
59-6000308
08101102
08101102
02/28/03
03/01-02/29
CLAIMS PROCESSOR: FLEX ONE
1932 WYNNTON ROAD
COLUMBUS, GA 31999
SUSAN RUBY
CITY ATTORNEY
Affiliated Employers which will participate in the Plan:
11) Employer's Type of Business
OTHER
5
FLEXIBLE BENEFITS PLAN SUMMARY PLAN DESCRIPTION
Introduction
Your employer (the "Employer") ~s pleased to sponsor an employee beneht program known as a "Flex~ble Benefits Plan" (the
"Plan") for you and your fellow employees. Under Federal tax laws, it is also known as a "cafeteria plan". It ~s so called
because ~t lets you choose from several d~fferent ~nsurance and fringe benefit programs according to your individual needs
The Employer provides you wKh the opportunity to use pre-tax dollars to pay for them by entering into a salary redirection
arrangement instead of a corresponding amount of your regular pay. This arrangement helps you because the benefits you
elect are nontaxable; you save social security and income taxes on the amount of your salary redirecbon. Alternabvely, your
employer may allow you to pay for any of the available benehts w~th after-tax contributions on a salary deducbon bas~s.
This Summary Plan Description describes the basic features of the Plan, how it operates, and how you can get the maximum
advantage from it. The booklet is only a summary of the key parts of the Plan, and a brief description of your rights as a
parhcipant. It ~s not a part of the official plan documents. If there is a confhct between them and th~s booklet, the plan
document will apply.
By enrolling in the Flexible Spending Account (FSA) option and submitting FSA claims you specifically authorize the Plan,
AFLAC and FLEX ONE, and their respecbve agents, employees, sub-contractors, and assigns to use your personal
reformation m their possession to administer the Plan (including the evaluation of eligibility for reimbursement under the Plan)
and to detect or prevent fraud or misrepresentation, and to further disclose such informabon as ~s reasonably required for those
purposes. You further authorize any provider, insurer, or other entity to release any health or treatment information for the
purpose of determining elig~bd~ty for Plan benefits or for detecting or preventing fraud or m~srepresentabon. You further waive
and release any claims related to the use, disclosure, or release of such information so long as the information is used m
furtherance of administering the Plan (including processing or evaluabng a claim for benefits under the Plan) or to detect or
prevent fraud or misrepresentation. This authorization does not and is not intended to in any way limit any right the Plan,
AFLAC and FLEX ONE , or their respective agents, employees, sub-contractors, and assigns may have under apphcable State
or Federal law or regulation regarding the use of such information.
PART I
General Information about the Flexible Benefits Plan
Questions & Answers
O-1. What is the purpose of the Plan?
The purpose of the Plan is to allow eligible employees to use funds provided by the Employer through employee salary
redirection, to choose one or more of the Benefit Plans or Policies offered through the Plan, and enable them to pay for the
selected coverage(s) with pre-tax dollars.
Q-2. What Benefits can I purchase on a pre-tax basis through the Plan?
You will be able to choose to participate in the Plan's pre-tax program options by filling out any required enrollment form(s) for
the component Benefit Plan or Policy. The Plan may also permit you to select Unre~mbursed Medical Care Expense
Reimbursement or Dependent Care Expense Reimbursement on a pre-tax basis. To the extent described on enrollment
materials, employees who opt-out of certain benefits may be entitled to additional cash compensation. The various benefit
options available will be described to you in information materials distributed prior to each enrollment period. For the detads
regarding eligibility provisions, benefit amounts, and premium schedules, please refer to the plan summary of each of the
above programs. Ask the Plan Administrator for copies.
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0-3. Who can participate in the Plan?
Each employee of the Employer is eligible to participate in the Plan who meets the descnpbon of eligible Employee in the
Employer Information Section. Those employees who actually parbcipate in the Plan are called "Participants". An employee
continues to partic,pate until he or she: i) elects not to participate in accordance with Q-7; or ii) is no longer employed by the
Employer, or Continuation Coverage (as described below) is no longer in effect.
Q-4. What tax advantages are available through the Plan?
The Plan permits you to pay for insurance and fringe benefit programs with pre-tax dollars through salary redirecbon rather than
regular pay. You should note, however, that paying for coverage on a pre-tax basis may cause insurance claim payments
under health and medical coverage to be subject to Federal and State taxes if claim payments from all health and medical
pohcies/plans are in excess of medical expenses relating to the condition which triggers the payment You will be responsible
for including such excess amounts (if any) in your tax return. Paying for disability income policies with pre-tax premiums will
cause the benefits payable thereunder to be taxable. Alternatively, you may be permitted to pay for the same benefits with
after-tax dollars on a salary deduction basis. The Plan may also permit you to select Unreimbursed Medical Care Expense
Reimbursement or Dependent Care Expense Reimbursement on a pre-tax basis if these benefits are selected by your
Employer as noted in the Employer Information Section.
Q-5. How do I become a participant?
You become a Participant by signing an individual Salary Redirection Agreement on which you elect one or more of the
benefits available under the Plan, as well as agree to a salary redirection to pay for those benefits so elected. You will be
provided a Salary Redirection Agreement when you first become eligible to participate. You must complete the form and turn it
in to the Personnel Office within the time period specified by the Plan Administrator. If you are eligible on the initial Effective
Date of the Plan, you will be able to enter the Plan during the Initial Enrollment Period and shall become a Participant on the
date set forth in the Employer Information Section. Otherwise, you will be able to enter the Plan on the effective date of your
coverage under the component Beneht Plans or, Policies. In future years, a new Salary Redirection Agreem. ent will be made
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Mike and Sharon consbtutes a Change m Status An election to cancel coverage for Sharon ~s consistent w~th th~s Change m
Status However, an elect~on to cancel coverage for M~ke and/or the child ~s not consistent w~th th~s Change ~n Status In
contrast, an election to change to employee-plus-one-dependent coverage would be consistent with this Change ~n Status
However, if you, your Spouse, or a Dependent elect COBRA continuation coverage under the Employer's plan, you may be
able to increase your contribution to pay for such coverage.
(b) Gain of Coverage Eligibility Under Another Employer's Plan. For a Change in Status ~n which you, your Spouse,
or your Dependent gain eligibility for coverage under another employer's cafeteria plan (or qualified benefit plan) as a result of
a change m your marital status or a change in your, your Spouse's, or your Dependent's employment status, your elect~on to
cease or decrease coverage for that individual under the Plan would correspond with that Change m Status only if coverage for
that indwldual becomes effective or is increased under the other employer's plan.
(c) Dependent Care Expense Reimbursement Benefits. With respect to the Dependent Care Expense
Reimbursement benefit, you may change or terminate your election only if: (1) such change or termination ~s made on account
of and conforms with a Change in Status that affects eligibility for coverage under the Plan; or (2) your election change is on
account of and conforms w~th a Change ~n Status that affects the ehg~bility of dependent care or adoption assistance expenses
for the available tax exclusion.
Example: Employee Mike is married to Sharon, and they have a 12 year old daughter The employer's plan offers a
dependent care expense reimbursement program as part of its cafeteria plan Mike elects to reduce his salary by $2,000
during a plan year to fund dependent care coverage for h~s daughter. In the m~ddle of the plan year when the daughter turns
13 years old, however, she is no longer eligible to p,~rticipant in the dependent care program. This event constitutes a Change
~n Status. Mike's election to cancel coverage under the dependent care program would be consistent w~th this Change in
Status.
(d) Group Term Life insurance, Disability Income, or Dismemberment Benefits. For group term life insurance,
disability income and dismemberment benefits, ~f you experience any Change ~n Status (as described above), you may elect
either to increase or decrease your coverage.
Example: Employee Mike is married to Sharon and they have one child. The employer's plan offers a cafeteria plan which
funds group-term I~fe insurance coverage (and other benefits) through salary redirection Before the plan year Mike elects
$10,000 of group-term life insurance. Mike and Sharon subsequently divorce during the plan year The divorce constitutes a
Change in Status. An election by Mike either to increase or to decrease his group-term life insurance coverage would both be
consistent with this Change in Status.
2. Special Enrollment Rights. If you, your Spouse and/or a Dependent are entitled to special enrollment rights under a
group health plan, you may change your election to correspond with the special enrollment right. Thus, for example, if you
declined enrollment in medical coverage for yourself or your eligible dependents because of outside medmal coverage and
eligibility for such coverage is subsequently lost due to certain reasons (i.e., due to legal separation, divorce, death, termination
of employment, reduction in hours, or exhaustion of the maximum COBRA period), you may be able to elect medical coverage
under the Plan for yourself and your eligible dependents who lost such coverage. Furthermore, if you have a new dependent
as a result of marriage, b~rth, adopbon, or placement for adoption, you may also be able to enroll yourself, your Spouse, and
your newly acquired dependents, provided that you request enrollment within 30 days after the marnage, b~rth, adoption, or
placement for adopbon. Please refer to the group health plan description for an explanabon of special enrollment rights.
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3. Certain Judgments and Orders. If a judgment, decree or order from a divorce, separation, annulment or custody change
requires your Dependent chdd (including a foster child who is your tax Dependent) to be covered under this Plan, you may
change your election to provide coverage for the Dependent child. If the order requires that another individual (such as your
former spouse) cover the Dependent chdd, you may change your election to revoke coverage for the Dependent child.
4. Entitlement to Medicare or Medicaid. If you, your Spouse, or a Dependent becomes entitled to Medicare or Medicaid,
you may cancel that person's accident or health coverage. Similarly, if you, your Spouse, or a Dependent who has been
entitled to Medicare or Medicaid loses elig~bdity for such, you may, subject to the terms of the underlying plan, elect to begin or
increase that person's accident or health coverage.
5. Change in Cost. If the Plan Administrator notifies you that the cost of your coverage under the Plan significantly increases
or decreases during the Plan Year, regardless of whether the cost change results from acbon by you (such as switching from
full-time to part-time) or the Employer (such as reducing the amount of Employer contributions for a certain class of
employees), you may make certain elect~on changes. If the cost significantly increases, you may choose either to make an
increase m your contributions, revoke your election and receive coverage under another Benefit Plan or Policy which provides
similar coverage, or drop coverage altogether if no similar coverage exists. If the cost significantly decreases, you may revoke
your elect~on and elect to receive coverage provided under the option that decreased in cost. For insignificant increases or
decreases in the cost of Benefit Plan(s) or Policy0es), however, the Plan Administrator will automatically adjust your election
contributions to reflect the minor change m cost The Plan Administrator (in its sole d~scretion) will determine whether the
requirements of this section are met. (Please note the above "Change in Cost" exceptions are not applicable to Medical Care
Expense Reimbursement accounts under the Plan).
5 SPD
Q-11., Will I have any administrative costs under the Plan?
Unless otherwise indicated m the Employer Informabon Secbon, the Employer ~s bearing the enbre cost of admimstermg the
Plan.
Q-12. How long will the Plan remain in effect?
Although the Employer expects to maintain the Plan indefinitely, ~t has the right to modify or terminate the program at any time
It is also possible that future changes in State or Federal tax laws may require that the Plan be amended accordingly
Q-13. What happens if a Request for Reimbursement is denied?
If your request ~s for a benefit under one of the component Benefit Plan(s) or Policy(ies), you will generally proceed under the
reimbursement procedure applicable under the component Benefit Plan or Pohcy. However, ~f you are denied a benefit under
this Plan including a benefit under the Medical Care Expense Reimbursement Plan and/or the Dependent Care Expense
Reimbursement Plan (such as the abd~ty to pay for premiums on a pre-tax basis) due to an ~ssue germane to your coverage
under this Plan (i.e., such as a determ~nabon of' a Change m Status; a "s~gn~flcant" change in premiums charged, or elig~bd~ty
and participation matters under the Flexible Benefits Plan document), the reimbursement procedure under th~s Plan will apply,
and you will be notified in writing by the Plan's Administrator w~thin 30 days of the date you submitted your request if the
request is denied. Such notification wdl set out the reasons your request was denied, and further adwse you of what steps, ~f
any, you might take to validate the claim request. It wdl further adwse you of your right to request an administrative rewew of
the denial of the request. Th~s 30-day penod may be extended 15 days ~f the Plan Adm~mstrator determines that an extension
is necessary for reasons beyond the Plan Administrator's control. You will be nobfied, m writing, if an extension is necessary.
If the extens,on is necessary because you failed to submit the necessary ~nformation to dec~de the claim, the written nobce will
indicate what information is required and you will have 45 days from receipt of the notice to prowde the required ~nformation
You may request a review of a denied claim any tl~3e within the 180-day period after you have received notice that the request
was demed You or your authorized representabve wdl have the opportumty to review, free of charge, all "relevant" (as
determined by the Plan Administrator in accordance w~th apphcable rules and regulations) documents held by the Administrator
and to submit comments and other supporting information. A decision will be reached within 60 days of the date of your
request for a review. If your claim is den~ed on review, in whole or part, you may file suit ~n Federal or State court. If you fad to
make a timely applicabon for administrative review of the demal, you lose your right to sue in State or Federal court.
Q-14. What is "Continuation Coverage" and how does it work?
"Continuation Coverage" means your right, or your spouse and dependents' nght, to continue to be covered under any of the
component medical benefit plans if the Employer is subject to COBRA (i.e., typically employs 20 or more employees) and
participabon by you (including your spouse and dependents) otherwise would end due to the occurrence of a "Qualifying
Event." A Qualifying Event is:
-termination of your employment (other than by reason of gross misconduct);
-or reduction of your work hours;
-your death;
-divorce or legal separation from your spouse;
-your becoming entitled to receive Medicare benefits;
-when a dependent of yours ceases to be a dependent.
For a Qualifying Event, other than a change in your employment status, it will be your obligation to inform the appropriate Plan
Administrator of each medical benefit plan you have elected of its occurrence within 60 days of the occurrence The
appropriate Plan Admin,strator, in turn, has a legal obhgation to furnish you, or your spouse, as the case may be, w~th separate,
written options to continue the coverages provided at stated premium costs with respect to each health plan in which you are a
participant. The notification you will receive will explain the terms and conditions of the continued coverage.
Certain Medical Care Expense Reimbursement Expense Account Participants will be eligible for COBRA Continuation Coverage
~f they have a positive Medical Care Expense Reimbursement Account balance at the time of a Qualifying Event (taking into
account all claims submitted before the date of the quahfying event) You will be not~fied if you are eligible for COBRA
Conbnuation Coverage. However, even if COBRA is offered for the year ~n which the qualifying event occurs, COBRA coverage
for the Medical Care Expense Reimbursement Account will cease at the end of the year and cannot be continued for the next
plan year.
Q-15. What effect will Plan participation have on Social Security and other benefits?
Plan participation will reduce the amount of your taxable compensation. Accordingly, there could be a slight decrease in your
Social Security benefits and/or other benefits (e.g., pension, disability and life insurance) which are based on taxable
compensation.
Q-16. What happens if I take a leave of absence?
(a) If you go on a qualifying unpaid leave under the Family and Medical Leave Act of 1993 (FMLA), to the extent required by
the FMLA, the Employer will continue to maintain your Benefits Plans or Pohc~es providing health coverage (including the
Medical Care Expense Reimbursement Benefit) on the same terms and conditions as though you were st, II active (i.e, the
Employer will continue to pay ~ts share of the contnbution to the extent you opt to continue coverage.
(b) Your Employer may elect to continue all coverage for Participants while they are on paid leave (provided Participants on
non-FMLA paid leave are required to continue coverage). If so, you will pay your share of the contnbutions by the method
normally used during any pa~d leave (for example, on a pre-tax salary redirection bas~s if that is what was used before the
FMLA leave began).
7 sPo
-are married, but you furmsh more than one-half the cost of ma,ntamlng those Dependents for whom you are ehgible
to receive tax-free reimbursements under the DDC, your Spouse maintains a separate residence for the last 6 month
of the calendar year, and you file a separate tax return, or
-are single, or a head of household for tax purposes.
If you are married, reside together, but file a separate Federal income tax return, the maximum DDO benefit you
may elect is $2,500.
Q-5. How is my Medical Care and/or Dependent Care Expense Reimbursement benefit paid for and what amounts
will be available at any particular time during the Plan Year?
For URM, when you complete the Salary Red~recbon Agreement, you specify the amount of Medical Care and/or Dependent
Care Expense Reimbursement(s) you wish to pay for with your salary red~recbon Thereafter, you must pay a premium for
such coverage by hawng an equal portion of the annual pram,urn deducted from each paycheck. Your employer will distribute
benefit payments from ~ts general assets. For Medical Care Expense Reimbursement Benefits, the full amount of the coverage
you have elected, reduced by the amount of pnor reimbursements received during the Year, wdl be available to reimburse you
for your out-of-pocket medical expenses at any time during the Plan Year, provided that you have continued to pay the periodic
contnbubons due for this benefit. For DDC, the amount that is avadable to your Account at any particular time will be whatever
has been credited to such Account less any reimbursements already paid.
Q-6. How do I receive reimbursement under the Plan?
If you elect to participate in URM or DDC, you will have to take certain steps to be reimbursed for your Eligible Medical and/or
Eligible Employment Related Expenses (as defined below). When you incur an expense that is eligible for payment, you
submit a request to the Plan's Administrator on a Request for Reimbursement form that will be supplied to you.
For URM, you must include written statement(s)/bdt(s) from an independent third party(les) stating that the medical expenses
have been incurred, and the amount of such expense(s) along w~th the Request for Reimbursement form. In addition, you must
include an Explanation of Benefits (EOB) form(s) from any primary medical and/or dental insurance carrier(s) indicating the
amount(s) which you are obligated to pay.
For DDC, if your reimbursement request is for an amount that is more than your current Account balance, the excess part of the
reimbursement will be carried over into following months, to be paid out as your balance becomes adequate. Remember that
you can't be reimbursed for any total Dependent Care expenses above your available annual credits to your Account
With respect to either DDC or URM benefits, you may not be reimbursed for any expenses that arise before your Salary
Redirection Agreement becomes effective, or for any expense incurred after the close of the Plan Year.
To have your Request for Reimbursement processed as soon as possible, please read the reimbursement instruction you have
been furnished. Please note that it is not necessary that you have actually paid an amount due for Eligible Medical and/or
Eligible Employment Related Expenses -- only that you have recurred the expense, and that it is not being paid for or
reimbursed from any other source. In addit,on, you will have 90 days after the end of the Plan Year in which to submit a
Request for Reimbursement form for Eligible Expenses incurred during the previous Plan Year. You will be notified in writing ~f
any Request for Reimbursement is denied.
Q-7. What is an "Eligible Expense?"
For URM, an "Eligible Expense" generally means any item for which you could have claimed a medical expense deduction
on an itemized Federal income tax return, (without regard to any threshold limitation)for which you have not otherwise
been reimbursed from insurance, or some other source ("Eligible Medical Expense") You should note, however, that
Section 125 of the Internal Revenue Code places addibonal restrictions on such expenses. For example, premiums for
accident or health insurance are not Eligible Medical Expenses. Aisc, expenses for long-term care services are not eligible.
For DDC, You may be reimbursed for work-related expenses incurred on behalf of any individual in your family who is under
age 13 who resides with you and for whom you could claim as a Dependent exemption on your Federal income tax return; any
other Dependent who is mentally or physically incapable of caring for himself or herself; or your Spouse, if the Spouse is
likewise physically or mentally incapacitated ("Eligible Employment Related Expenses"). Generally, these expenses must
meet all of the following conditions for them to be Ehgible Employment Related Expenses:
1. The expenses are incurred for services rendered after the date of your election to receive Dependent Care Expense
Reimbursement, and during the calendar year to which it applies.
Each individual for whom you incur the expenses is
(a) Dependent under age 13 whom you are entitled to a personal tax exemption as a Dependent, or
(b) a Spouse or other tax dependent who is physically or mentally incapable of caring for himself or herself.
The expenses are incurred for the care of a Dependent (as described above), or for related household services, and are
incurred to enable you to be gainfully employed.
If the expenses are incurred for services outside your household and such expenses are incurred for the care of a
Dependent who is age 13 or older, such Dependent regularly spends at least 8 hours per day in your home.
If the expenses are incurred for services provided by a dependent care center (i.e., a facility that provides care for more
than 6 individuals not residing at the facility), the center complies with all applicable State and local laws and regulations.
The expenses are not paid or payable to a child of yours who ~s under age 19 at the end of the year in which the expenses
are incurred or an individual for whom you or your spouse is entitled to a personal tax exemption as a Dependent.
This reimbursement (when aggregated with all other Dependent Care Reimbursements during the same year) may not
exceed the least of the following limits:
(1) $5,000
9 SPD
~1-14., Forfeiture of Unclaimed Reimbursement Account Benefits.
Any Reimbursement Account benefit payments that are unclaimed (e g., uncashed benefit checks) by the close of the Plan
Year follow~ng the Plan Year m which the Dependent Care Expense was incurred shall be forfeited.
Q-15. What happens to my Reimbursement Account(s) when I take a leave of absence?
The affect of a leave of absence on your Reimbursement Account(s) is described in Q-16 of Part I.
PART III
Premium Benefits
You will be able to choose to participate in one or more of the component insurance or fringe benefit programs designated in
the Employer Informabon Section by separately filling out any required enrollment form(s) for the component Benefit Plan or
Policy You should then select your chosen method for funding the coverage(s) (pre-tax or after-tax) by indicating your choice
or choices on the Salary Redirection Agreement, and financing your share of the cost by pre-tax salary redirection or after-tax
salary deduction, as described earlier.
For the details regarding eligibility provisions, benefit amounts, and premium schedules, please refer to the plan summary of
each, separate plan that will be furnmhed to you by the Plan Administrator
PART IV
Electing Less Than The Maximum Annual Benefit
Any portion of your Compensation that you do not choose to apply toward the purchase of the benefits described above will be
paid to you as regular, taxable Compensation.
PART V
ERISA Rights
The Flexible Benefits Plan is not an ERISA welfare benefit plan. However, certain component Benefit Plans or Policies (e.g.,
such as the URM benefit may be subject to ERISA. As a participant in an ERISA-covered Plan, you are entitled to certain rights
and protections under the Employee Rebrement Income Secunty Act ("ERISA"). ERISA provides that all plan participants shall
be entitled to.
Receive Information About Your Plan and Benefits
-Examine, without charge, at the Plan Administrator's office and at other specified locations, such as work-sites and union hails,
all plan documents, including insurance contracts, collective bargaining agreements and copies of all documents filed by the
Plan with the U.S. Department of Labor, such as detailed annual reports and plan descnpt,ons.
-Obtain, upon written request to the Plan Administrator, copies of all documents governing the operation of the plan, including
insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 series) and
updated Summary Plan Description. The Plan Administrator may make a reasonabie charge for the copies.
-Receive a summary of the Plan's annual financial report. The Plan Administrator is required by law to furnish each participant
with a copy of this summary annual report.
Continue Group Health Plan Coverage
Continue health coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a
qualifying event. You or your dependents may have to pay for such coverage. Review this Summary Plan Description and the
documents governing the plan on the rules governing your COBRA continuation coverage rights. Reduction or elimination of
exclusionary periods of coverage for preexisting conditions under your group health plan, if you have creditable coverage under
another plan You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health
insurance issuer when you lose coverage under the plan, when you become entitled to elect COBRA continuation coverage,
when your COBRA continuabon coverage ceases, if you request it before losing coverage, or if you request it up to 24 months
after losing coverage. Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion for 12
months (18 months for late enrollees) after your enrollment date in your coverage.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation
of the employee benefit plan. The people who operate your plan, called "fiduciaries" of the plan, have a duty to do so
prudently and in the interest of the plan participants and beneficiaries. No one, including your employer, your union, or any
other person, may fire you or otherwme d~scriminate against you in any way to prevent you from obtaining a (pension, welfare)
benefit from the plan, or from exercising your rights under ERISA.
Enforce Your Rights
If your claim for a welfare benefit under an ERISA-covered plan is denied in whole or in part, you must receive a written
explanation of the reason for the denial. You have the right to have the Plan review and reconsider your claim. Under ERISA,
there are steps you can take to enforce the above rights. For instance, if you request materials from the Plan and do not
receive them within 30 days, you may file suit m a Federal court. In such a case, the court may require the Plan Administrator
to provide the materials and pay you up to $110 a day until you receive the materials, unless-the materials were not sent
because of reasons beyond the control of the Administrator. If you have a claim for benefits which is denied or ignored m
whole or part, you may file suit in a State or Federal court In addition, if you disagree with the Plan's decision or lack thereof
concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court.
If it should happen that plan fiduciaries m~suse the Plan's money, or if you are discriminated against for asserting your rights,
you may seek assistance from the U.S. Department of Labor, or you may file suite in a Federal court. The court w~ll decide
,.
11 S~D
PRIVACY PRACTICES
Protecting the privacy and confidentiahty of employer and participant Information through FLEX ONE~'s cafeteria
service plans is very important to American Family Life Assurance Company of Columbus (AFLAC®) and
American Famdy Life Assurance Company of New York (AFLAC New York). Throughout th~s notice when we use
the name "AFLAC" we will be referring to both organizations. Accordingly, we strive to comply wfth each of the
following practices in everything we do.
- We do not sell, rent, lease or otherwise disclose personal information about employers or employees
of an employer for purposes unrelated to our products and services. The personal information of our
customers ~s of paramount ~mportance to us. Therefore, we provide this ~nformat~on only to our employees,
agents and third parties as required to allow them to help us develop and prowde our ~nsurance and employee
benefit products and services.
- We work to ensure information integrity and security. We use technology tools and design our business
practices to help ensure that the personal reformation of the employ, er and employees of the employer are
properly gathered, stored and processed. We also work to maintain the secunty of, and internal and external
access to, the personal information of our customers through the use of technology and our business practmes.
- We expect our agents and employees to respect the personal information of our customers. ^FLAC
has business policies and practices in place to help ensure that its employees and agents carry out these
practices and otherwise protect the personal reformation. Both employees and agents are subject to censure,
dismissal or termination for violation of these policies.
These Privacy Practices apply to our U.S. customers. Due to legal and cultural differences, our practices may
vary outside the United States.
PRIVACY NOTICE
AFLAC and our agents provide this notice to let you know about the current privacy practices of AFLAC, and our
agents. You do not need to do anything in response to this notice, This notice is merely to inform you
about how we safeguard your information.
Collection of Information
As part of AFLAC's normal operating procedures, AFLAC (and our agents acting on our behalf) need to obtain
information from both the employer and the participant to service the flexible spending accounts. AFLAC and our
agents may collect nonpublic personal information (which includes both nonpublic personal financial information
and nonpublic personal health information) about AFl_AC customers, including but not limited to:
- Information from the employer or the participant (including names, addresses, Social Security numbers, financial
and marital status, and health and dependent child-care information);
- Information about the employer or the participant's transaction with AFl_AC or our agents (including claims,
payment information and banking information);
- Information from the employer or the participant's health care providers (including drug receipts and medical
information), employers (including benefit elections and employment information) and family members.
Disclosure of Information
ACLAC r~ay disclose the nonpublic personal financial information we collect, as described above, as well as
information about your transactions with us (such as elect~on amounts, premiums and payment history) to our
agents or other third parties who perform services for us or functions on our behalf, including the marketing of
AFl_AC services. AFl_AC may also disclose the nonpublic personal financial information we collect to other third
parties as authorized by you, or as required or permitted by law. Our agents will make d~sclosures of the
employer or the participants' nonpublic personal financial information only while acting on AFLAC's behalf and,
furthermore, will make such disclosures only as AFLAC itself is permitted to make. Neither AFl_AC nor our
agents will use or share with other parties any nonpublic personal health information about our customers for any
purpose other than the servicing of the employer's flexible spending account plan by AFl_AC or on our behalf or
to which the customer consents Neither AFl_AC nor our agents will further disclose any nonpublic personal
health informabon about a former customer of AFLAC other than as may be required or permitted by law.
Confidentiality and Securit~
AFL. AC and our agents will safeguard, according to strict standards of security and confidentiality, any information
we collect, receive or maintain about AFLAC's customers. AFl_AC maintains administrative, technical and
physical safeguards to ensure the security and confidentiality of the employer and employees, and the employer
information and records; to protect against anticipated threats or hazards to such records; and to protect against
unauthorized access to or use of such information or records.
Internally, AFLAC limits access to our customers' information to only those employees who need access to the
information to perform their job functions. Employees who misuse information are subject to disciplinary actions.
Externally, we do not disclose customer information to any third parties unless we have previously informed the
customer of the disclosure, have been authorized to do so by the customer, or are required or permitted to make
the disclosure by law or our regulators.
FlexPrlv
L4C
ADMINISTRATIVE
SERVICES
The #1 Provider of
Cafeteria Plan Services
AFl. AC Admtmstrative Services · FLEX ONE' · A Service of Amcrtc.m F,mfily Life As.,,uranc¢ Company of Colt, rebus (AFLAC)
Worldwide Headquarters' 1932 Wynnton Road · Coftm~bu,. (;corgt,~ 31999 · Phone (800) 323-5391
A-14091 -G
Dear JOSEPH SAFFORD:
04-23-02
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Welcome to AFLACe's FLEX ONEe, the #1 provider of cafeteria plan services! Enclosed in this packet are the
documents necessary to establish a cafeteria plan with the assistance of FLEX ONEe. Please carefully review the
Flexible Benefits Plan Document and Summary Plan Description to verify that all of the information regarding
benefits offered, eligibility, plan administrabon and funding appear correctly You should note that these
documents are only sample documents typical of a plan intended to qualify as a Secbon 125 cafeteria plan with
the terms and condibons thereof, and that they may need to be modified to conform to your individual
circumstances.
AFLAC has developed these documents with legal counsel and it is AFLAC's intent and belief that the
documents in form satisfy the requirements of Code Section 125. However, AFl_AC is not in the business of
offering legal counsel or tax advme, and thus AFl_AC cannot and does not make any representations about the
legal or tax effect of these documents upon any particular employer. Therefore, it is each employer's
responsibility to determine, with the assistance of the employer's own legal counsel, the sultabH~ty of these
particular documents and the legal and tax effect of these plan documents upon the employer and ~ts employees.
Since AFLAC has no control over your subsequent modification and/or administration of the Plan, and the Internal
Revenue Service will not render an opinion as to a plan's qualified status under IRS Code Section 125, AFl_AC
makes no representation (express or imphed) as to your Plan's qualihcation under IRS Code Secbon 125 and
related provisions as it is adopted and subsequently amended.
You as sponsoring employer bear sole responsibility for amending your plan (as necessary) to comply with future
tax law changes, for meeting all reporting and disclosure requirements imposed by applicable law, and for the
daily administration of your plan. As such, we recommend you review the following important information:
Important Compliance Issues
Form 5500 Annual Reports - All employers that sponsor a cafeteria plan are required to file a Form 5500 annual
report by the Internal Revenue Code. A separate Form 5500 may need to be filed to sabsfy any ERISA imposed
obligations. ERISA filing obligations will arise whenever there are 100 or more participants in any particular
Benefit Plan or Policy. Failure to file a Form 5500 annual report could result in the imposition of fines by the IRS
or Department of Labor (DOL). As set forth in the checklist of Plan Sponsor responsibilities included in the Plan
Document Request form, each plan sponsor is responsible for ensuring that it files any required Form 5500
returns AFLAC will provide certain insurance information for its coverage required for plan sponsors to complete
Schedule A of their Form 5500 filing This insurance information will automatically be generated when there are
100 or more AFl_AC policyholders m any type of AFLAC insured product, and will also be provided to other plan
sponsors upon request.
Nondiscrimination Testing is at the very core of the legal requirements imposed by Section 125 of the Internal
Revenue Code. Each cafeteria plan sponsor must ensure that its plan satisfies all applicable nondiscrimination
requirements imposed by the Internal Revenue Code. Failure to satisfy these requirements w~ll cause adverse
tax consequences to highly compensated employees and could possibly disqualify the plan. At a m~nimum, each
plan sponsor should undertake nondiscrimination testing near the beginning and end of each plan year, and
whenever there is a substantial change in the participation and/or elections under the plan.
Company Affiliations - If your company is related to any other company through stock ownership or otherwise
(e.g., partnership, relatives owning other company, etc.), you may need to consider the employees of the
affiliated company for purposes of nondiscrimination testing even if the affiliated company does not adopt this
plan, or adopts an enbrely separate plan. In addition, if the requirements of IRS Code Section 414 (b), (c), (m) or
(o) are satisfied, the employees of the affihated company may be able to participate in this plan. You should
consult with your tax adwsor concerning the potential impact of IRS Code Section 414(b), (c), (m) and (o).
Certain Insurance Premiums which cover the employee (or in the case of coverage other than life insurance,
the employee and tax dependents/family) may be included in the FLEX ONE® Plan Documents if adopted as part
of your benefits plan. These include:
-Group Term Life Insurance covering the employee (Eligible under IRS Code Section 79) that is equal to
or less than $50,000 (life insurance coverage on dependents is not eligible for pre-tax treatment);
-Accidental Death and Dismemberment (AD&D) coverage;
-Medical, Dental, Hospital Indemnity, Cancer Insurance, Vision, Hearing and other qualified accident and
health premiums.
Please note: When including health, medical and disability income policies within the FLEX ONE® Plan: Paying
for coverage on a pre-tax bas,s may cause ~nsurance benefit payments under medical coverage to be subject to
Federal and State taxes if benefit payments from all medical policies/plans are in excess of medical expenses.
Covia!
Due to the complexity of cafeteria plans, we recommend that you consult with your accountant, attorney or other
tax advisor concerning the plan provmions, admmmtration and operation before executing the plan documents.
Remember that your cafeteria plan will not be effective until your plan is adopted, and the plan documents must
be signed PRIOR TO THE EFFECTIVE DATE. If your plan document is executed subsequent to the effective
date, the IRS may attempt to challenge the quahfied status of your plan. We recommend you retain any
evidence you have that would establish your plan was adopted and enrollments were completed prior to the
effecbve date. In the event there have been no pre-tax deducbons taken thus far, you may consider changing the
start date of your cafeteria plan.
AFLAC will make its best efforts to provide employers information about developments concerning Section 125
plans. However, for reasons stated above, it is the employer's responsibility to maintain the qualified status of the
Section 125 plan, in form and in operation. Should you have any questions concerning the FLEX ONE® Cafeteria
Program, you may contact us at 1-800-323-5391 between the hours of 8:30 a.m. and 7:00 p.m. Eastern Time,
Monday through Friday.
We are pleased you've chosen AFLAC's FLEX ONE® to help you meet your cafeteria plan needs and we look
forward to the opportunity to serve you.
Sincerely,
Robert M. Ottman
Second Vice President
AFLAC Administrative Services/FLEX ONEe
Covlet
TABLE OF CONTENTS
FLEXIBLE BENEFITS PLAN
PREAMBLE
ARTICLE I DEFINITIONS
1.01
1.02
1.03
1.04
1.05
1.06
1.07
1 .O8
1.09
1.10
1.11
1.12
1.13
1.14
1.15
1.16
1.17
1.18
1.19
1.20
1.21
1.22
1.23
1,24
1.25
1.26
1.27
1.28
1.29
1.30
1.31
1.32
1.33
1.34
1.35
"Affiliated Employer"
"After-tax Premium(s)"
"Anniversary Date"
"Benefit Plan(s) or Policy(les)"
"Board of Directors"
"Change in Status"
"Code"
"Compensation"
"Dependent"
"Dependent Care Expense Reimbursement"
"Earned Income"
"Effective Date"
"Eligible Employment Related Expenses"
"Eligible Medical Expenses"
"Employee"
"Employer"
"ERISA"
"Highly Compensated Individual"
"Key Employee"
"Medical Care Expense Reimbursement"
"Nonelective Contributions"
"Participant"
"Plan"
"Plan Administrator" or "committee"
"Plan Year"
"Pre-tax Premium(s)"
"Qualified Benefit"
"Qualifying Employment-Related Expenses"
"Qualifying Individual"
"Qualifying Services"
"Reimbursement Account(s) or Account(s)
"Salary Redirection Agreement"
"Spouse"
"Student"
"Trustee"
ARTICLE II ELIGIBILITY AND PARTICIPATION
2,01 Eligibility to Participate
2.02 Entry Date
2.03 Termination of Participation
2.04 Eligibility to Participate in Reimbursement Benefits
2.05 Qualifying Leave Under Family and Medical Leave Act
2.06 Non-FMLA Leave of Absence
ARTICLE III PREMIUM ELECTIONS
3.01 Election of Premiums
3.02 Initial Election Period
3.03 Annual Election Period
3.04 Change of Premium Election
3.05 Termination of Election
ARTICLE IV PREMIUM PAYMENTS AND CREDITS AND DEBITS TO ACCOUNTS
4.01 Source of Premium Payments
4,02 Allocations Irrevocable During Plan Year
4.03 Reduction of Certain Elections to Prevent Discrimination
4.04 Medical Care Expense Reimbursement
4.05 Dependent Care Express Reimbursement
ARTICLE V BENEFITS
5.01 Qualified Benefits
5.02 Cash Benefit
5.03 Repayment of Excess Reimbursements
5.04 Termination of Reimbursement Benefits
5.05 ,. COBRA Coverage
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PREAMBLE
The Employer hereby estabhshes a Flexible Benehts Plan ("Plan") for ~ts Employees for purposes of prowdmg ehgible
Employees w~th the opportunity to choose from among the fringe benefits available under the plan. The Plan is intended to
qualify as a cafeteria plan under the prowslons of Code Section 125. The Dependent Care Expense Reimbursement Plan
("DDC") ~s intended to qualify as a Code Section 129 dependent care assistance plan, and the Medical Care Expense
Reimbursement Plan ("Health FSA") is intended to qualify as a Code Section 105 medical expense reimbursement plan.
Although printed w~thin this document, the DDC and Health FSA Plans are separate written plans for purposes of administrabon
and all reporting and nondiscrimination requirements ~mposed by Sections 105 and 129 of the Code and all applicable
provisions of ERISA. The DDC and Medical Care Expense Reimbursement Plans are available only ~f designated on the
Adoption Agreement.
FLEXIBLE BENEFITS PLAN
ARTICLE I
DEFINITIONS
1.01 "Affiliated Employer" means any Employer w~thin the context of Code Section 414(b), (c), or (m) of the Code which will
be treated as a single employer for purposes of Code Section 125.
1.02 "After-tax Premiums(s)" means amounts withheld from an Employee's Compensation pursuant to a Salary Redirection
Agreement to purchase coverages available under the Adoption Agreement on an after-tax basis.
1.03 "Anniversary Date" means the first day of any Plan Year.
1.04 "Benefit Plan(s) or Policy(ies)" means those Qualified Benefits available to a Participant under the Adoption
Agreement. Where a Benefit Plan or Pohcy is made available through an ~nd~vldual insurance policy, the insurer(s) and policy
form numbers shall be listed in Appendix A.
1.05 "Board of Directors" means the Board of D~rectors of the Employer. The Board of Directors, upon adoption of this Plan,
appoints the Committee to act on the Employer's behalf m all matters regarding the Plan.
1.06 "Change in Status" means any of the events described below, as well as any other events included under subsequent
changes to Code Section 125 or regulations issued under Code Section 125 which the Plan Administrator (in its sole discretion)
decides to recognize on a uniform and consistent basis:
(a) Legal Marital Status: A change in a Participant's legal marital status, including marriage, death of a Spouse, divorce,
legal separation or annulment;
(b) Change in Number of Tax Dependents (as defined in Section 1.09): A change in the Participant's number of tax
Dependents, including the birth of a child, the adoption or placement for adoption of a Dependent, or the death of a
Dependent.
(c) Change In Employment Status: Any change in employment status of the Participant, the Participant's Spouse or the
Participant's Dependents that affects benefit eligibility under a cafeteria plan (including this Plan or other employee
benefit plans (including the Benefit Plan(s) or Policy(les) of the employer of the Participant, the Spouse or
Dependents), such as: termination or commencement of employment; a str~ke or lockout; a commencement of or
return from an unpaid leave of absence; a change in worksite; switching from salaried to hourly paid; union to non
union; or part-time to full-time; incumng a reduction or increase in hours of employment; or any other similar change
which makes the individual become (or cease to be) eligible for a particular employee benefit.
(d) Dependent Eligibility Requirements: An event that causes a Participant's Dependent to satisfy or cease to satisfy
the Dependent eligibility requirements for a particular benefit, such as attaining a specified age, getting married, or
ceasing to be a Student.
(e) Change in Residence: A change in the place of residence of the Participant, the Participant's Spouse or the
Participant's Dependent.
1.07 "Code" means the internal Revenue Code of 1986, as amended.
1.08 "Compensation" means the cash wages or salary paid to an Employee by the Employer.
1.09 "Dependent" means any individual who is a tax dependent of the Partmipant as defined in Code Section 152(a), or who is
determined to be an alternative recipient of a Plan Part|c~pant under an order determined to be a qualified medical child support
order (QMCSO) by the Plan Administrator, provided however, that in the case of a divorced Employee: i) Dependent shall be
defined as in Code Section 21(e)(5) (e g., dependent of the parent with the custody) for purposes of the Dependent Care
Expense Account Plan; and ii) for purposes of accident or health coverage, a child shall be considered a dependent of both
parents.
1.10 "Dependent Care Expense Reimbursement" shall have the meaning assigned to it by Section 5.01(c) of the Plan.
1.11 "Earned Income" means all income derived from wages, salaries, tips, self-employment, and other Compensation (such
as disability or wage continuation benefits), but only if such amounts are includible in gross income for the taxable year. Earned
income does not include (a) any amounts received pursuant to any Dependence Care Reimbursement Plan established under
Code 129; or (b) any other amounts excluded from earned income under Code 32 (c)(2), such as amounts received under a
pension or annuity, or pursuant to workers' compensation.
3 Plandoc
term life insurance coverage that is includable m gross income by virtue of exceeding the dollar limitation on nontaxable
coverage under Code Sec. 79) Long-term care insurance is not a "Qualified Benefit"
1.28 "Qualifying Employment-Related Expenses" means those expenses that would be considered to be employment-
related expenses under Section 21(b)(2) of the Code (relating to expenses for household and dependent care services
necessary for gainful employment) if pa~d for by the Employee to provide Qualifying Services.
1.29 "Qualifying Individual" means:
(a) a Dependent of the Participant who is under the age of thirteen (13); or
(b) a Dependent of a Participant who is mentally or physically incapable of caring for h~mself or herself; or
(c) the Spouse of a Participant who is mentally or physically incapable of caring for h~mself or herself
1.30 "Qualifying Services" means services relabng to the care of a Qualifying Individual that enable the Participant or Spouse
to remain gainfully employed which are performed:
(a) in the Participant's home; or
(b) outside the Parbcipant's home for (1) the care of a Dependent of the Participant who is under age 13, or (2) the care of
any other Qualifying Individual who resides at least eight (8) hours per day in the Participant's household. If the
expenses are incurred for services provided by a dependent care center 0.e., a facility that provides care for more than
6 ind~mduals not residing at the facility), the center must comply w~th all applicable State and local laws and
regulations.
1.31 "Reimbursement Account(s) or Account(s)" shall be the funding mechanism by which amounts are withheld from an
Employee's Compensation and retained for future. Medical Care Expense Remmbursement or Dependent Care Expense
Reimbursement. These amounts may either be retained by the Employer, sent to a thmrd party plan administrator, and/or kept
m trust for Employees No money shall actually be allocated to any individual Participant Account(s); any such Account(s) shall
be of a memorandum nature, maintained by the Administrator for accounting purposes, and shall not be representabve of any
identifiable trust assets, No interest will be credited to or paid on amounts credited to the Participant Account(s).
1.32 "Salary Redirection Agreement" means the actual or deemed agreement pursuant to which an eligible Employee or
Participant enrolls m the specific component Benefit Plans or Policies with Pre-tax Premiums or After-tax Premiums m
accordance w~th Article III. If the Employer utilizes an electronic (e g., electronic signature pad or digitized signature) or
interactive voice response (IVR) system for enrollment, the Salary Redirection Agreement may be maintained on an electronic
database.
1.33 "Spouse" means an individual who ms legally married to a Participant and who is treated as a Spouse under the Code, but
for purposes of the Dependent Care Expense Reimbursement Plan provisions, shall not include an individual legally separated
from the Parbcipant under a divorce or separate maintenance decree, nor shall it include an individual who, although married to
the Participant, files a separate Federal income tax return, maintains a separate, pnncipal residence from the Participant during
the last six months of the taxable year, and does not furmsh more than one-half of the cost of maintaining the principal place of
abode of the Qualifying Individual.
1.34 "Student" means an individual who, during each of five (5) or more calendar months during the Plan Year, is a full time
student at any college or university, the primary function of which is the conduct of formal instruction, and which routinely
maintains a regular faculty and curriculum and normally has an enrolled student body in attendance at the location where its
educational activities are regularly presented.
1.35 "Trustee" (if applicable) means the person(s) or institution (and their successors) named on the signature page attached
hereto, who have assented to being so named by their signature to this Agreement, otherwise empowered to hold and disburse
the funds that are created hereunder.
ARTICLE II
ELIGIBILITY AND PARTICIPATION
2.01 Eligibility to Participate. Each Employee who meets the criteria set forth in the Adoption Agreement shall be eligible to
participate in the Plan as of any applicable Entry Date. Eligibility for the benefits elected in the Adoption Agreement shall be
subject to the addlbonal requirements, if any, specified in the applicable Benefit Plan or Policy. The provisions of th~s Article
are not intended to override any eligibility requirement(s) or waiting period(s) specified in the applicable Benefit Plans or
Policies.
2.02 Entry Date. Each eligible Employee shall become a Participant in the Plan on the Entry Date specified in the Adoption
Agreement provided that he or she has satisfied the requirements of the Adoption Agreement,
2,03 Termination of Participation. Participation shall terminate on the earliest of: i) the date an Employee ceases to be an
Employee (except as otherwise provided in Section 3.05 for "COBRA coverage"); ii) when an Employee ceases to meet the
ehglbdity requirements of Section 2.01 of this Plan, iii) the date this Plan is amended to exclude the Employee or is terminated;
iv) the effective date of the Employee's election not to participate pursuant to Sections 3.03 or 3.04. Subject to any specific
limitations for any particular benefit which the Participant has elected: (a) participation shall be continued during a leave of
absence for which the Participant continues to receive a salary from his or her employer and (b) participation shall be
suspended dunng an unpaid leave of absence.
2.04 Eligibility to Participate in Reimbursement Benefits, An Employee, who is otherwise an Eligible Participant pursuant
to Secbons 2,01 and 2.02 shall be eligible to receive Medical and/or Dependent Care Expense Reimbursements (if selected by
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(c)
the Participant on th~s m~tlal Salary Redtrecbon Agreement shall be prospectively effective as of the first pay period
coinciding w,th or ~mmed~ately following the date that the Salary Red~recbon Agreement is filed (or ~f later, the date of
the employee's ehglbility under the Flexible Benefits Plan) and, sublect to Secbon 3 04, ending on the last day of the
Plan Year in which such parbclpat~on began Coverage under the component Benefits Plan or Pohc~es will be effecbve
in accordance w~th the ehgibdlty requirements contained in such Benefits Plans or Pohcles.
An eligible Employee who fails to complete, sign and file a Salary Redirection Agreement with the Plan
Administrator m accordance with paragraph (a) or (b) above during an initial election penod may become a participant
on a later date ~n accordance with Section 3.03 or 3.04.
3.03 Annual Election Period. Each Employee who is a Participant in this Plan or who is eligible to become a Participant in
this Plan shall be notified, prior to each Anniversary Date of this Plan, of his right to become a Participant in this Plan, to
continue participation in this Plan, or to modify or to cease participation m this Plan, and shall be given a reasonable per~od of
time in whmh to exercise such right. Such period of brae shall be known as the "annual election period" An Election shall be
made by subm~tbng a Salary Redirection Agreement to the Plan Administrator during the electron penod, and shall be effective
for the entire Plan Year beginning on the Anniversary Date. A Participant or Employee who fails to complete, sign and file a
Salary Redirection Agreement as required by this Secbon 3.03 shall be deemed to have elected to continue the same
coverage's under the Benefit Plans or Policies funded by the same election (e.g., either Pre-tax Premiums or After-tax
premiums adjusted to reflect any increase or decrease in premium/cost) then in effect for such Parbc~pant or Employee
Notwithstanding the foregoing, annual elect~ons for parbcipation m the Medical Care and Dependent Care Expense
Reimbursement Plans must be made by submitting a Salary Redirection Agreement prior to the beginning of each Plan year --
no deemed elect~ons shall occur under such Plans.
3.04 Change of Premium Election. A Participan: shall not make any changes to the Pre-tax Premium amount elected under
the Plan, or to the Participant's elected allocation of Nonelective Contributions 0f applicable), except for elecbon changes
permitted under this section 3.04, 2.04, 3 03 and 3.05 harem. Except as provided in Section 3.04(b) for HIPAA special
enrollment rights in the event of birth, adoption, or placement for adoption, all election changes shall be effective on a
prospecbve bas~s only (i.e., election changes will become effective no earher than the first day of the first pay period coinciding
with or immediately following the date that the election change was filed, but, as determined by the Plan Administrator, election
changes may become effective later to the extent the coverage in the applicable component plan commences later).
(a) Change in Status. A Parbcipant may change h~s or her actual or deemed election under the Plan upon the
occurrence of a Change in Status (as defined in Section 1.08), but only if such election change is made on account of
and corresponds with a Change ~n Status which affects ehgibdity for coverage under a plan of the Employer or a plan
of the Participant's Spouse's, or the Participant's Dependent's employer (referred to as the general consmtency
requirement). A Change in Status that affects eligibility for coverage under an employer's plan includes a Change in
Status that results in an increase or decrease in the number of an Employee's family members (i.e., a Spouse and/or
Dependents) who may benefit from the coverage. The Plan Administrator (in its sole discretion) shall determine, based
on prevadmg IRS guidance, whether a requested change is on account of and corresponds with a Change in Status.
Assuming the general consistency requirement is sabsfied, a requested election change must also satisfy the following
specific consistency requirements m order for a Participant to be able to alter his or her elecbon based on the
specified Change in Status:
(1) Loss of Dependent Eligibility. For a Change in Status involving a Participant's divorce, annulment or legal
separation from a Spouse, the death of a Spouse or Dependent, or a Dependent ceasing to satisfy the eligibility
requirements for coverage, a Participant may only elect to cancel accident or health insurance coverage for the
Spouse involved in the divorce, annulment, or legal separation, the deceased Spouse or Dependent, or the Dependent
that ceased to satisfy the ehgibility requirements. Canceling coverage for any other individual under these
circumstances would fail to correspond with that Change in Status.
Notwithstanding the foregoing, if the Participant's Spouse (but not a former Spouse) or the Participant's Dependent
becomes eligible for COBRA (or similar health plan continuation coverage under State law) under the Employer's Plan,
the Parbcipant may increase his or her election to pay for such coverage.
(2) Gain of Coverage Eligibility Under Another Employer's Plan. For a Change in Status in which a Participant, a
Participant's Spouse, or a Participant's Dependent gains ehgibdity for coverage under another employer's cafeteria
plan (or another employer's qualified benefit plan) as a result of a change m marital status or a change in employment
status, a Participant may elect to cease or decrease coverage for that indiwdual only if coverage for that individual
becomes effective or is increased under the other employer's plan.
(3) Special Consistency Rule for Dependent Care Expense Reimbursement Plans. With respect to the
Dependent Care Expense Reimbursement benefit when offered by the Plan, a Participant may change or terminate his
or her election upon a Change in Status: (i) if such change or terminabon is made on account of and corresponds with
a Change in Status that affects eligibility for coverage under an employer's plan; or (ii) the election change is on
account of and corresponds with a Change in Status that affects eligibility of dependent care expenses for the tax
exclusion available under Code Section 129
(4) Special Consistency Rule for Group Term Life Insurance, Disability and Dismemberment Coverage. For
any Change in Status, a Partm]pant may elect either to increase or to decrease group-term life insurance, disabdity
coverage, or accidental death and dismemberment coverage offered under the Plan.
HIPAA Special Enrollment Rights. If a Parttcipant, a Participant's Spouse or a Participant's Dependent is entitled to
special enrollment rights under a group health plan as required by HIPAA under Secbon 9801(f) of the Code, then a
Participant may revoke a prior election for group health plan coverage and make a new election (including an election
for Mad,cai Care Expense Reimbursement) provided that the election change corresponds with such HIPAA special
enrollment right. As required by HIPAA, a special enrollment right will arise if:
,.
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(ii) S~gmflcant Curtailment With a Loss of Coverage If the Plan Administrator determines that a Participant's
Benefit Plan or Pohcy under th~s Plan (or the Parbclpant's Spouse's or Dependent's coverage under his or her
employer's plan) is significantly curtailed, and such curtailment results m a Loss of Coverage during a Plan
Year, the Partm~pant may revoke his or her election for the affected coverage, and may either prospectively
elect coverage under another Benefit Plan or Policy that provides similar coverage, or drop coverage if no other
Benefit Plan or Policy providing similar coverage is available.
(iii) For purposes of th~s Section 3.04¢)(I), a "Loss of Coverage" means a complete loss of coverage (including
the ehmmatlon of a Benefit Plan or Policy, an HMO ceasing to be available where the Participant, Participant's
Spouse or Dependent resides, or a Participant, Spouse or Dependent losing all coverage under the Benefit Plan
or Policy by reason of an overall hfet[me or annual hm~tabon) In addition, the Plan Administrator, ~n ~ts
d~scretlon may treat events described m 1.125-4(f)(2)(i0 as a loss of coverage.
(2) Addition or Significant Improvement of a Benefit Plan or Policy. If during a Plan Year the Plan adds a new
Benefit Plan or Policy or slgmhcantly improves an ex~stmg Benefit Plan or Policy, the Plan Administrator may permit
the following election changes: (i) Participants who are enrolled in a Benefit Plan or Policy other than the newly added
or significantly improved Benefit Plan or Policy may change their election on a prospective basis to elect the
newly added or significantly improved Benefit Plan or Policy, and (il) Employees who are otherwise eligible under
Section 2.01 may elect the newly added or significantly improved Benefit Plan or Policy on a prospective basis,
subject to the terms and hm~tabons of the Benefit Plan or Policy. The Plan Administrator (in its sole discretion) will
decide, in accordance with prevadmg IRS guidance and on a uniform and consistent basis, whether there has been an
addition or a sigmficant ~mprovement of a Benefit Plan or Policy.
(3) Loss of Coverage under other Group Health Coverage. A Participant may prospectively change his or her
elecbon to add group health coverage for the Participant, the Participant's Spouse, or the Participant's Dependent, if
such individual(s) loses coverage under any group health coverage sponsored by a governmental or educabonal
insbtubon, including (but not hmlted to) the following: a State children's health insurance program ("SCHIP") under
Title XXI of the Social Security Act; a medical care program of an Indian Tnbal government (as defined in section
7701(a)(4)), the Indian Health Service, or a tnbal organization; a State health benefits risk pool; or a foreign government
group health plan, subject to the terms and limitations of the applicable Benefit Plan(s) or Policy(les).
(4) Change in Coverage under another Employer Plan. A Participant may make a prospective election change
that ~s on account of and corresponds with a change made under another employer plan (including a plan of the
Employer or another employer), so long as (i) the other cafetena plan or qualified benefits plan permits its participants
to make an election change that would be permitted under apphcable IRS regulations; or (ii) the Plan permits
Participants to make an election for a Plan Year which is d~fferent from the plan year under the other cafetena plan or
qualified benefits plan. The Plan Administrator shall determine, based on prevailing IRS guidance, whether a
requested change is on account of and corresponds with a change made under the other employer plan.
Any change in an elecbon affecting annual Plan contributions to the Medical or Dependent Care Expense Reimbursement Plans
pursuant to this Section also will change the maximum Reimbursement Benefits for the period of coverage remaining in the
Plan Year. Such maximum Reimbursement Benefits for the penod of coverage following an election change shall be calculated
by adding the balance (~f any) remaining in each of the Participant's Reimbursement Accounts as of the end of the portion of
the Plan Year immediately preceding the change ~n election, to the total Plan Contributions scheduled to be made by the
Participant during the reminder of such Plan Year to such Account(s).
An employee who is eligible to become a Participant but declined to become a Participant dunng the initial election period
pursuant to Section 3.02(a) or (b) may become a Participant and file a Salary Redirection Agreement within thirty (30) days of
the occurrence of an event described m Secbon 3.04 above, but only if the elect~on under the new Salary Redirection
Agreement is made on account of and corresponds with the event (as described above). A Participant otherwise entitled to
make a new election under this Section must do so within thirty (30) days of the event (e.g., Change in Status, s~gmficant
change in cost or coverage, Medicare or Medicaid eligibility, special enrollment nght or judgment, decree, or order).
Elections made pursuant to this Section shall be effective for the balance of the Plan Year in which the election is made unless
a subsequent event (described above) allows a further election change.
3.05 Termination of Election. Except as otherwise provided in Section 2.03, Terminabon of employment shall automatically
revoke any Salary Redirection Agreement. Except as provided below, if revocation occurs under this Section 3.05, no new
election with respect to Pre-tax Premiums may be made by such Participant during the remainder of the Plan Year.
ARTICLE IV
PREMIUM PAYMENTS AND CREDITS AND DEBITS TO ACCOUNTS
4.01 Source of Premium Payments. The Employer shall withhold from a Participant's Compensation on a Pre-tax or After-
tax bas~s (as elected on the Salary Redirection Agreement) an amount equal to the contributions required from the Participant
(less any applicable Nonelective Contribution) for coverage of the Participant, or the Participant's Spouse or Dependents, under
the Benefit Plans or Pohc~es elected by the Participant and maintained by the Employer as noted in the Adopbon Agreement
under this Plan The component Benefit Plans or Policies and required Employee contributions thereunder shall be set forth on
an annual schedule and/or disclosed to Participants m enrollment material. Amounts w~thheld from a Participant's
Compensation as Pre-tax Premiums or After-tax Premiums shall be applied to fund benefits as soon as administratively
feasible. The maximum amount of Pre-tax Premiums plus any Nonelective Contributions made available by the Employer
for the benefit of each Plan Participant shall not exceed the aggregate cost of the benefits elected
4.02 Allocations Irrevocable During Plan Year. Except as provided in Secbons 3.04, 3.05, 4 03 and 4.04, neither: 0) the
insurance coverages nor amounts withheld therefore elected under Section 5.01(a), nor (ii) the ar~ount to be credited to a
9 Plandoc
lc)
(1) are not covered, paid or reimbursed from any other source; and
(2) meet the criteria of tax-deductlbdity as a medical or dental expense under Section 213 of the Code, as amended
and the regulations thereunder; and
(3) meet any limitations imposed by applicable regulations promulgated under Code Section 125; and
(4) wdl not be taken as a deduction from income on the Participant's Federal income tax return in any tax year; and
(5) do not exceed the lesser of: la) the maximum annual amount allocable to Medical Care Expense Reimbursement
specified m the Adoption Agreement, or lb) the annual amount that the Employee has elected to have w~thheld for
Medical Care Expense Reimbursement; less previous Medical Care Expense Reimbursements made during the Plan
Year; and
(6) are verified ~n writing to the satmfaction of the Admimstrator that a covered expense has occurred and the
reimbursement for which meet the substantiation requirements of Section 6.11.
Dependent Care Expense Reimbursement. If pursuant to the Adoption Agreement, the Employer has elected to
maintain a Dependent Care Expense Reimbursement Plan, payment shall be made to the Parhcipant in cash as
reimbursement for Eligible Employment Related Expenses incurred by him or her wh~le an Employee, during the Plan
Year for which the Participant's election is effective, provided that the substantiabon requirements of Section 6.11 have
been complied with. No payment otherwise due a Participant hereunder shall exceed that smallest of:
(1) the Participant's Earned Income for the applicable month; or
(2) the Earned Income of the Participant's Spouse for such month (Note: a Spouse of a Participant who ~s not
employed during a month in which the Participant incurs Eligible Employment Related Expenses and who ~s either
Incapacitated or a Student shall be deemed to have Earned Income m the amount of $200 per month per Qualifying
Individual for whom the Partmlpant incurs Eligible Employment Related Expense(s), up to a maximum amount of $400
per month); or
(3) the annual amount the Participant has elected to have withheld from his Compensabon for Dependent Care
Expense Reimbursement less any prior Dependent Care Expense Reimbursements during the Plan Year; or
(4) F~ve Thousand Dollars ($5,000), or, if the Participant is married and files a separate tax return, Two Thousand Five
Hundred Dollars ($2,500) (or any future aggregate hm~tations promulgated under Code Section 129) less any prior
reimbursements during the Plan Year.
5.02 Cash Benefit. Employees who elect not to receive coverage under certain Employer sponsored plans may be entitled to
additional cash compensabon as described in the Adoption Agreement under "Opt-out Option". To the extent that a Participant
does not elect under a Salary Redirection Agreement to have the maximum amount of his Compensabon contributed as a Pre-
tax Premium or After-tax Premium hereunder, such amount not elected shall be pa~d to the Participant in the form of normal
Compensation payments; provided however, that Nonelective Contributions may not be received m the form of cash
compensation.
5.03 Repayment of Excess Reimbursements. If, as of the end of any Plan Year, it is determined that a Participant has
received payments under this Plan that exceed the amount of Eligible Reimbursement Expenses that have been substantiated
by such Participant during the Plan Year, the Plan Administrator shall give the Participant prompt written notice of any such
excess amount, and the Participant shall repay the amount of such excess to the Employer within s~xty (60) days of receipt of
such notification.
5.04 Termination of Reimbursement Benefits. Coverage under the Medical Care Expense Reimbursement and/or
Dependent Care Expense Reimbursement Plan(s) shall cease as of the date on which a Participant is no longer employed by
the Company or when a premium payment has not been made for any reason. Provided, however, that Participants shall have
the right to submit Claims for reimbursement for Eligible Employment-Related Expenses arising during the Plan Year at any
time untd ninety (90) days after the end of the Plan Year for which the election had been ~n effect, and to receive
reimbursement hereunder. Participants in the Medical Reimbursement Plan shall have the right to submit claims for
reimbursement for Eligible Medical Expense arising during the Plan Year and before the date of separation from service at any
time until ninety (90) days after the end of the Plan year for which the election had been in effect, and to receive reimbursement
hereunder. Unless a COBRA election is made, Participants shall not be entitled to receive reimbursement for Medical Care
expenses incurred after coverage ceases under this Section, and any unused reimbursement benefits at the expiration of the
90-day period following the close of the Plan Year shall be treated in accordance with Sections 4 04 or 4.05.
5.05 Coordination of Benefits Under Health FSA. The Health FSA is intended to pay benefits solely for otherwise
unre~mbursed medical expenses Accordingly, it shall not be considered a group health plan for coordination of benefits
purposes, and its benefits shall not be taken into account when determining benefits payable under any other plan.
ARTICLE VI
PLAN ADMINISTRATION
6.01 Allocation of Authority. Except as to those functions reserved within the Plan to the Employer, the Plan Administrator
appointed pursuant to the Adoption Agreement shall control and manage the operation and administration of the Plan. The Plan
Admimstrator shall have the exclusive right to interpret the Plan and to decide all matters arising thereunder, including the right
to make determinations of fact and construe and interpret possible ambiguibes, inconsistencies, or omissions in the Plan and
the Summary Plan Description issued m connection w~th the Plan. All determinations of the Plan Admimstrator with respect to
any matter hereunder shall be conclusive and binding on all persons. Without limiting the generahty of the foregoing, the Plan
Administrator shall have the following powers and duties:
la) To require any person to furnish such reasonable information as he may request for the purpose of the proper
adm~mstration of the Plan as a condition to receiving any benefits under the Plan;
lb) To make and enforce such rules and regulations and prescribe the use of such forms as he shall deem necessary for
the efficient administrabon of the Plan;
11 Plandoc
FIt~xible Benefits Plan Document) Th~s Article shall be the claims procedure apphcable to the Medical Care Expense
Reimbursement and the Dependent Care Expense Reimbursement Plan(s).
8.02 Procedure if Benefits are Denied under the Plan. Any Employee, benehc~ary, or h~s duly authorized representabve
may hie a claim for a benefit to which the claimant beheves that he is entitled, but that has been previously den~ed by the Plan
Administrator. Such a claim must be in writing and delivered to the Plan Administrator in person or by mall, postage paid.
Within thirty (30) days after receipt of such claim, the Plan Administrator shall send to the claimant, by ma~l, postage prepaid,
notice of the granbng or denying, in whole or in part, of such claim, unless special c~rcumstances require an extension of time
for processing the claim. In no event may the extension exceed fifteen (15) days from the end of the initial period, if such
extension ~s necessary, the claimant will be given a written notice to th~s effect pnor to the expiration of the m~tial 30-day period
If an extension of time is necessary because the claimant failed to provide sufficient information necessary to dec,de the claim,
the nobce of the extension shall describe the required mformabon and the claimant shall have forty-five (45) days from the
receipt of such notice to provide the required informabon. The Plan Administrator shall have full d~screbon to deny or grant a
claim in whole or m part. If notice of the denial of a claim is not furnished in accordance with this Section 8.02, the claim shall
be deemed denied and the claimant shall be permitted to exercise his nght to review pursuant to Sections 8.04 and 8 05.
8.03 Requirement for Written Notice of Claim Denial. The Plan Administrator shall provide a written notice to every
claimant who ~s denied a claim for benefits under this Article. Such written notice shall set forth in a manner calculated to be
understood by the cla,mant, the following information.
(a) The specific reason or reasons for the denial;
(b) Specific reference to pertinent Plan provisions on which the denial ~s based;
(c) A description of any additional material or information necessary for the claimant to perfect the claim and an
explanation of why such material ~s necessary; and
(d) An explanation of the Plan's claim review procedure.
8.04 Right to Request Hearing on Benefit Denial. Within 180 days after the receipt by the claimant of written notificabon of
the denial (in whole or in part) of his claim, the claimant or his duly authorized representabve may make a written application to
the Plan Administrator, in person or by certified mall, postage prepaid, to be afforded a review of such denial; may review
pertinent documents; and may submit msues and comments in writing.
8.05 Disposition of Disputed Claims. Upon receipt of a request for review, the Plan Administrator shall make a prompt
decision on the review matter The decision on such review shall be written in a manner calculated to be understood by the
claimant and shall include specific reasons for the decision, specihc references to the pertinent plan or insurance policy
provisions on which the decmlon was based, and a descripbon of any voluntary appeal procedures offered by the Plan. The
dec,sion upon review shall be made not later that sixty (60) days after the Plan Administrator's receipt of a request for a review.
ARTICLE IX
AMENDMENT OR TERMINATION OF PLAN
9.01 Permanency. While the Employer fully expects that this Plan will continue indefinitely, due to unforeseen, future
business contingencies, permanency of the Plan w~ll be sublect to the Employer's right to amend or terminate the Plan, as
prowded in Sections 9.02 and 9.03, below. Nothing m this Plan is intended to be or shall be construed to entitle any
Participant, rebred or otherwise, to vested or nonterm~nable benefits.
9.02 Employer's Right to Amend. The Employer reserves the right to amend the Plan at any brae and from time-to-time,
and retroactively, ~f deemed necessary or appropnate to meet the requirements of Code Section 125, or any similar provisions
of subsequent revenue or other laws, to modify or amend ~n whole or in part any or all of the provisions of the Plan. All
amendments shall be made in writing and shall be approved by the Board of D~rectors (or a duly authorized officer of the
Employer) in accordance with its normal procedures for transacting business. Such amendments may apply retroactively or
prospectively. Each Benefit Plan or Policy shall be amended ~n accordance with the terms specified therein, or, if
no amendment procedure is prescribed, in accordance with th~s section. Any amendment made by the Employer shall be
deemed to be approved and adopted by any Affiliated Employer.
9.03 Employer's Right to Terminate. The Employer reserves the right to disconbnue or terminate the Plan without prejudice
at any time and for any reason without prior nobce. Such decision to terminate the Plan shall be made in writing and shall be
approved by the Board of Directors (or a duly authorized officer of the Employer) in accordance with its normal procedures for
transacbng business. Affiliated Employers may withdraw from participation in the plan, but may not terminate it.
9.04 Determination of Effective Date of Amendment or Termination. Any such amendment, discontinuance or
termination shall be effective as of such date as the Employer shall determine. Subject to Sections 4.04(a) and 4.05(a) (if
applicable), no amendment, disconbnuance or termination shall allow the return to any Employer of any Reimbursement
Account balance nor its use for any purpose other than for the exclusive benefit of the Participants and their beneficiaries.
ARTICLE X
GENERAL PROVISIONS
10,01 Not an Employment Contract. Neither this Plan nor any acbon taken with respect to it shall confer upon any person
~- the r~ght to continue employment with any Employer
~ ~o 10.02 Applicable Laws. The provisions of the Plan shall be construed, administered and enforced according to applicable
· .04 Federal law and the laws of the State of the principal place of business of the Employer to the extent not preempted.
~ C~
..... 03 13 Plandoc
10.17' Forfeiture of Unclaimed Reimbursement Account Benefits. Any Reimbursement Account beneht payments that
are unclaimed (e.g, uncashed beneht checks) by the close of the Plan Year following the Plan Year in which the Health or
Dependent Care Expense was incurred shall be forfeited
ARTICLE Xl
CONTINUATION COVERAGE UNDER COBRA
The following provis,ons shall be applicable to the Medical Care Expense Reimbursement Plan, and any other group health
plan (as defined by Code Sections 4980B and 5000(b)(1) and the regulations promulgated thereunder) subject to COBRA that
does not otherwise contain COBRA provisions. As noted m Section 11.05, COBRA coverage need not be extended to certain
Health Care Expense Account Participants. The intent of this Article is to extend contmuabon rights required by COBRA To
the extent greater rights are provided for hereunder, th~s Article shall be void
11.01 Continuation Coverage after Termination of Normal Participation. During any Plan Year during which the
Employer is subject to Code Sectfon 4980B, each person who is a Quahfied Beneficiary shall have the right to elect to continue
coverage under the Medical Care Expense Reimbursement Plan (or other group health plan subject to COBRA) upon
the occurrence of a Qualifying Event that would otherwise result in such person losing coverage hereunder. Such extended
coverage under the plan ,s known as "Continuation Coverage".
11.02 Who is a "Qualified Beneficiary". A "Qualified Beneficiary" is any person who ~s, as of the day before a Qualifying
Event: (a) an Employee of the Employer (including persons who are considered to be "employees" within Code Sec. 401(c),
directors and independent contractors) covered under a health plan offered under the Plan as of such day (such persons are
called "Covered Employees"), (b) the Spouse of the Covered Employee, or (c) a Dependent of the Covered Employee. A
Covered Employee can be a Qual,hed Beneficiary only if the Qualifying Event consists of termination of employment (for any
reason other that gross misconduct) or reduction of hours of the Covered Employee's employment. A chdd born to or placed
for adoption with a Covered Employee during Continuation Coverage will also be a Qualified Beneficiary. A rebree or other
former Employee actively participating in the Plan by reason of a prewous period of employment wdl be treated as a "Qualihed
Beneficiary ".
11.03 Who is not a "Qualified Beneficiary". A person is not a Qualified Beneficiary if, as of such day, e~ther the individual
is covered under the Medical Care Expense Reimbursement Plan (or other group health plan subject to COBRA) by virtue of
the election of Continuation Coverage by another person and is not already a Qualified Beneficiary by reason of a prior
Qualifying Event, or is entitled to Medicare coverage under Title XVIII of the Social Security Act. Furthermore, an individual
who fails to elect Continuation Coverage within the election period provided in Section 11.07, below, shall not be considered to
be a Qualified Beneficiary.
11.04 What is a "Qualifying Event". Any of the following shall be considered as a "Qualifying Event":
(a) death of a Covered Employee; or
(b) termination (other than by reason of gross misconduct) of the Covered Employee's employment or reduction of hours
of employment; or
(c) divorce or legal separation of a Covered Employee's spouse; or
(d) a Covered Employee's becoming entitled to receive Medicare benefits under Title XVIII of the Social Security Act; or
(e) a dependent child of a Covered Employee ceasing to be a Dependent.
In the case of any person treated as a "Covered Employee" but who is not a common-law employee, termination of
"employment" means termination of the relationship that originally gave rise to eliglbihty to participate in the Medical Care
Expense Reimbursement Plan (or other group health plan subject to COBRA)
11.05 COBRA Not Applicable to Certain Health Care Expense Account Participants. In accordance with IRS
regulations, COBRA contmuabon coverages will not be offered to Medical Care Expense Account Plan participants under
certain circumstances:
(a) Unavailability of COBRA in Plan Year in Which Qualifying Event Occurs. COBRA continuation coverage will not
be offered to a Qualified Beneficiary in the Plan Year in which the Qualifying Event occurred if:
(1) Conditions in 11.05(b) are Satisfied. The Medical Care Expense Account Plan satisfies the conditions set forth
in Section 11.05(b), and
(2) Health Care Expense Account has a Deficit at the Time of the Qualifying Event. Taking into account all
claims submitted on or before the date of the Qualifying Event, the Qualified Beneficiary's remaining Medical Care
Expense Account balance for the Plan Year is less than the maximum required COBRA premiums for the rest of the
year (i.e., the Medical Care Expense Account is in a deficit position).
Unavailability of COBRA in Subsequent Plan Years. COBRA continuation will not be offered to a Medical Care
Expense Account Participant m any Plan Year following the Plan Year in which the Qualifying Event occurs (thus even
if COBRA is offered for the year in which the qualifying event occurs, the COBRA coverage will cease at the end of the
year and cannot be continued for the next plan year);
(1) Health FSA is Exempt from HIPAA. The Medical Care Expense account is exempt from HIPAA (i.e, a major
medical plan is available in addition to the Medical Care Expense Account, and the Medical Care Expense Account
benefit does not exceed two times the salary redirection or, if greater, the salary red[factions plus $500), and
(2) COBRA Premiums Equals or Exceeds Medical Care Expense Account Benefit. If for the plan year in
which the Qualifying Event occurs, the maximum amount the Qualified Beneficiary could be required to pay for a full
year of Medical Care Expense Account COBRA coverage equals or exceeds the maximum benefit available to the
Qualified Beneficiary for the plan year.
The Plan Administrator will notify Medical Care Expense Account Participants as to their COBRA ehgibility (if any).
15 Plandoc
ADOPTION AGREEMENT FOR:
CITY OF DELRAY BEACH
FLEXIBLE BENEFITS PLAN
ESTABLISHMENT OF THE PLAN
The Employer named below established as set forth herein, a Flexible Benefits Plan (the "Plan") as of the Effective Date
consisting of this Adoption Agreement, the Plan Document and the Benefit Plans and Policies specifically referred to hereto
including the Dependent Care Expense Reimbursement Plan and/or a Medical Care Expense Reimbursement Plan The
purpose of the Flexible Benefits Plan is to provide ehglble employees a choice between cash and the specified welfare benefits
described m th~s Adoption Agreement Pre-tax premium elecbons under the Plan are intended to quahfy for the exclusion from
income provided in Section 125 of the Internal Revenue Code of 1986
EMPLOYER INFORMATION
1) Name and Address of Employer/
CITY OF DELRAY BEACH
Plan Administrator:
2) Employer's Telephone Number:
3) Employer's Federal Tax ID Number:
4) 125 Start Date:
5) Effective Date of the Plan:
6) L~ist Day of the Plan Year:
Subsequent Plan Years:
7) Name and Address of the Plan
Service Provider:
8) Name and Title of Registered Agent
for Service of Legal Process:
9) Affiliated Employers which will Participate in the
JOSEPH SAFFORD
100 NW 1ST AVE
DELRAY BEACH, FL 33444
(561) 243.7116
59-6000308
08101102
08101/02
02128103
03101-02/29
CLAIMS PROCESSOR: FLEX ONE
1932 VVYNNTON ROAD
COLUMBUS, GA 31999
SUSAN RUBY
CITY ATTORNEY
Plan:
m
mm
m
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EMPLOYER'S ACKNOWLEDGMENT
As evidenced by the formal execution of this Adoption Agreement, the undersigned Employer adopted and established this Plan on
the Effective Date as the Flexible Benefits Plan of the undersigned Employer, In doing so, the undersigned Employer
acknowledges that this Adoption Agreement and this Plan are important legal instruments w~th sigmficant legal and tax imphcations
The Employer also acknowledges that it has read this Adoption Agreement and the Plan ~n their entirety, has consulted
independent legal and tax counsel other than representatives of American Family Life Assurance Company of Columbus (AFLAC®),
to the extent considered necessary, and accepts full responsibility for participation of employees hereunder and the operabon of the
Plan The Employer acknowledges that as Plan Sponsor and the Plan Administrator, ~t shall have sole responsibility to comply with
all flhng, reporting and disclosure requirements ~mposed by the Department of Labor, Internal Revenue Service, or any other
government agency, specifically including, but not limited to, creating and filing Form 5500s and preparing and distributing
Summary Plan Descriptions Furthermore, the Employer further acknowledges that it shall bear sole responsibility for amending
the Plan as necessary to ensure comphance with applicable tax, labor, and other laws and regulations. Employer acknowledges
receipt of the checklist of Plan Sponsor Responsibilities included in the Plan Document Request form and has agreed to the
obligations set forth therein.
It is also understood and agreed that Amedcan Family Life Assurance Company of Columbus (AFl_AC) and its Subsidiaries, agents,
and representatives, are not prowding legal or tax advice to the undersigned Employer in connection with this Plan and that no
representations, are made by it with respect to the operation of the Flexible Benefits Plan pursuant to the sample documents
provided by American Family L~fe Assurance Company of Columbus (AFL.AC) to the Employer.
This Plan shall be construed and enforced according to the Internal Revenue Code of 1986, as amended from time to time, the
applicable regulations thereto and the laws of the State of the principal place of business of the Employer.
IN WITNESS WHEREOF, the Employer has caused th~s Plan and Adoption Agreement to be executed on the day of
j'~'~,' , ~.~..~,J~' 7_.g3~"Z~ to ratify the adoption of the Plan adopted and effective as of the Effective Date.
WITNESS:
Co~ora~Officer -- -~ ', ' ~
MEMORANDUM
To;
David T. Harden, City Manager
From:
Joseph M. Safford, Finance Director
Date: April 10, 2002
Subject:
Employee Benefit Plan Design
As previously discussed, the City of Delray Beach is presently designing a package of
voluntary benefits to be offered to employees If an employee is required by the Internal
Revenue Service (IRS) to elect either pre-tax or post-tax benefits, i.e. during an annual
enrollment process, the benefits will have to be incorporated into a Section 125 Cafeteria
Plan.
If the employees are not allowed, by IRS regulation, to make an election to receive a
benefit pre-tax or post-tax, these additional benefits will be provided outside the Section
125 Cafeteria Plan.
Therefore, to summarize the various benefits to be provided in our new package, we
would offer the following:
Section 125 Cafeteria (Flexible Benefit) Plan
Employee will be given a one-time per year election to choose the following benefits
either pre-tax or post-tax. Employee must maintain their election for the entire plan year
unless there is a qualifying event which would allow a change in their election.
· Group (Dependent) Medical Insurance Plan (Code Section 105 and 106)
Premium Only Plan (POP)
This plan allows employees to make an annual election to make premium
payments to the Cigna group health plan with pre-tax dollars (or after-tax dollars)
for dependent health insurance premiums.
· Group Dental/Vision Insurance Plan (Code Section 105 and 106)
Premium Only Plan (POP)
This plan allows employees to make an annual election to make premium
payments to the City's dental/vision group plan with pre-tax dollars (or after-tax
dollars) for employee and dependent dental and vision insurance premiums.
· Personal Cancer Care Protector Insurance Plan (Code Section 105 and 106)
Premium Only Plan (POP)
This plan allows employees to make an annual election to make premium
payments to the AFLAC Personal Cancer Protector Plan with pre-tax dollars (or
after-tax dollars) for employee and dependent cancer expense insurance
premiums.
,at ~
Personal Recovery Plus Insurance Plan (Code Section 105 and 106)
Premium Only Plan (POP)
This plan allows employees to make an annual election to make premium
payments to the AFLAC Personal Recovery Plus Plan with pre-tax dollars (or
after-tax dollars) for employee and dependent heart attack, stroke, coronary artery
bypass surgery, paralysis, major burns, coma, end-stage renal failure, and major
organ transplant expense insurance premiums.
Personal Volnntary Indemnity Plan (Code Section 105 and 106)
Premium Only Plan (POP)
This plan allows employees to make an annual election to make premium
payments to the AFLAC Personal Voluntary Indemnity Plan with pre-tax dollars
(or after-tax dollars) for employee and dependent hospital confinement, surgery,
rehabilitation, heart attack, stroke, coma, paralysis, ambulance, etc. expense
insurance premiums.
Personal Accident Expense Plan (Code Section 105 and 106)
Premium Only Plan (POP)
This plan allows employees to make an annual election to make premium
payments to the AFLAC Personal Accident Expense Plan with pre-tax dollars (or
after-tax dollars) for employee and dependent accident emergency treatment,
follow-up treatment, hospitalization, hospital confinement, intensive care
confinement, physical therapy, prosthesis benefit and appliance benefit, blood and
plasma, ambulance, transportation, family lodging, and wellness benefit expense
insurance premiums.
Medical Flexible Spending Arrangements (FSA Plan)
This plan (Code Section 105 and 106) allows employees to set aside funds to use
pre-tax dollars to reimburse medical, dental, optical care, deductibles, co-pays,
and prescription drug costs not covered by insurance. Unused amounts are
forfeited at year-end.
Dependent Care Flexible Spending Arrangement (FSA Plan)
This plan (Code Section 129) allows employees to set aside funds (up to a
maximum of $5,000, or $2,500 if married filing separately) to use pre-tax dollars
to reimburse dependent care expenses. This benefit can only be used if both
spouses are working on a daily basis. If either the employee or spouse is not
working on a daily basis, then you are not eligible for reimbursement. The intent
of this benefit is to allow both parents to work. Dependent care includes:
1. Care for a child under the age of 13 (age 12 or under) for whom you are
entitled to receive a personal tax exemption as a dependent or
2. Care for a spouse or other tax dependent, age 13 or over, incapable of
caring for him/herself and living with the employee
3.Household-related services (i.e. visiting nurse)
Unused amounts are forfeited at year-end
It should be noted that all Section 125 Cafeteria Plan benefits are elections by the
employee, are at employee cost, and are at no cost to the Employer.
Other Benefit Plans (Not Section 125 Flexible Benefit Plan)
· Life Assurance (Various Personal Life Insurance Policies and Riders)
Premium Only Plans (POP)
This plan allows employees to choose among several AFLAC term and whole life
insurance policies and riders and to make premium payments to AFLAC with
post-tax contributions. By paying the premiums post-tax, any life insurance
benefit payment would be received tax-free to the beneficiary.
· Section 529 Higher Education Expense Plan
This plan allows an employee to deposit post-tax contributions to a fund, invested
at the option and control of the employee, for use on higher education costs
(tuition, books, housing, etc.) on a tax-free basis. Funds remain under control and
ownership of employee which is important for a dependent or grandchild applying
for a scholarship or grant since these are not included in the assets of that
individual. Employee can change the recipient or beneficiary at any time.
· ICMA Vanta~eCare Retiree Health Savings Plan
This plan allows an employee to deposit accumulated sick and vacation time prior
to retirement pre°tax and use, following retirement, for medical premiums or other
medical costs not paid by insurance on a tax-free basis.
· Retiree Financial Planning Services
This planning service is proposed for employees within 5 years of retirement and
will include the following topics:
1. Retirement Planning
2. Estate Planning
3. Insurance Coverage
4. Cash Flow and Debt Management
5. Portfolio Management
6. Education Planning
These financial planning services are provided at no-charge to the employee.
It is extremely important to get the Section 125 Cafeteria Plan document in place and
approved by the City Commission since we have existing benefits in place pre-tax
without this document. This is an IRS regulation and includes the filing of 5500 tax
forms.
If this overall benefit package meets with your approval, we will proceed with the
Section 125 Cafeteria Plan document design by AFLAC as well as the documentation of
the non-Section 125 benefits. These final documents will be presented to you for
submission to the City Commission for a final approval process.
It would be recommended that we set up a meeting as soon as possible with Ned Gusty
and Susan Ruby regarding the question of what employee groups will be offered these
benefits.
Cc~
Ned Gusty, Human Resources Director
Susan Ruby, City Attorney