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HomeMy WebLinkAbout2009B M ~ ~~~ BEN EE[T MAflKETfNG SOLU TION35 Shipping: 10000 Shelbyville Road, Suite 110, Louisville, KY 40223 Mailing: P.O. Box 43653, Louisville, KY 40253-0653 (502) 244-1161 FAX (502) 244-1162 www.bmsllc.net Adoption Agreement-Flexible benefits Plan Employer Name: City of Jeffersonville Plan Year: January 1, 2009 to December 31, 2009 The undersigned Employer, by executing this Adoption Agreement, elects to amend the accompanying Flexible Benefits .Plan by adopting said plan document in full. The Employer makes the following elections granted under the provisions of the plan. 1. The Name of the Employer: City of Jeffersonville The Employer shall be the Plan Sponsor and Plan Administrator. 2. Effective Date: X This Flexible Benefits Plan shall be effective as of January 1, 2009. _ This amended Flexible Benefits Plan shall be effective as of _ If amended and restated, the Plan was originally effective on 3. Plan and Plan Year: The Name of the Plan shall be the City of Jeffersonville Flexible Benefits Plan (the "Plan"). This Plan Year shall begin on January 1, 2009 ,and end December 31, 2009 .Future Plan Years will be based on a full twelve-month period beginning each Januar.~ and ending each December 31St The initial, short, Plan Year shall begin on ,and end on _ Future Plan Years will be based on a full 12-month period beginning each ending each 4. Plan Number: 501 5. Employer's Principal Office: This Flexible Benefits Plan shall be governed under the laws of the: X State of Indiana Commonwealth of Kentucky 6. Eligible Employees: All Employees shall be eligible to participate in the Plan, except: and ^ Individuals who fail to qualify as an Eligible Individual for a Health Savings Account under Code Section 223(c) shall not be eligible to participate under the Health Savings Account portion of the Plan; ® 2008 BMS LLC Page 1 of 4 ^ Under the Healthcare Flexible Spending Account, any self-employed person(s), within the meaning of Code Section 401(c), including independent contractors, a greater than 2% shareholder in a Subchapter S corporation, a partner in a partnership, or any owner or member of a limited liability company that is treated like a partnership for tax purposes; ^ A relative, within the meaning of IRC Section 318, of one of the above self-employed person(s) AND: X Employees not eligible under Employer group health insurance plan. Part-time Employees expected to work less than thirty-seven and one half hours per week. Commissioned salespersons. _ Any Employee of the Employer who is included in a unit of employees covered by an agreement which the Secretary of Labor finds to be a collective bargaining agreement between employee representatives and one or more employers unless the collective bargaining agreement requires the employee to be included within the Plan. _ Any Employee who is temporary or seasonal (working for the Employer less than 6 months of the year). Any Leased Employee. Nonresident Aliens. Other: 7. Plan Entry Date: Employees eligible to participate may become Participants: X Same as Employer's group health insurance plan. _ days after date of hire. 8. Benefits: The following Benefit Options shall be included in the Plan: X Healthcare Flexible Spending Account subject to an annual limit of $ 1,500.00. This maximum applies to both a General Purpose Healthcare Flexible Spending Account or a Limited Purpose Healthcare Flexible Spending Account, (if you have a Health Savings Account) based on your Plan provisions. X Dependent Care Assistance Program subject to the maximums contained in Section 7.9 of the Plan Document. $ 5,000.00 . Adoption Assistance Program subject to the maximums contained in Section 8.9 of the Plan Document. _ Individual, Privately Held Health Insurance (Proof of Policy Coverage Required); X Insurance Benefits. The Employer's Sponsored Group Health Insurance Plans (including any Employer Sponsored Plans which can include: Health or Medical insurance, Dental insurance, Vision insurance, Accidental Death & Dismemberment insurance, Group Term Life Insurance on the © 2009 BMS LLC Page 2 of 4 life of the employee for coverage that does not exceed $50,000, Long or Short Term Disability Insurance; and premiums for COBRA Continuation Coverage payroll deducted for eligible employee); Tax-Free Transportation Program, subject to the terms and conditions of Article IX of the Plan Document; _ Employee Health Savings Account Contributions, subject to the terms and conditions of Article X of the Plan Document; 9. Contributions: The contributions for this Plan shall be: X Employee (Salary Redirection) contributions only; Employer Contributions only, which shall be: $ annually per Participant of which $ that is convertible to cash compensation; or _ Both Employee (Salary Redirection) and Employer Contributions. 10. Claims Extension Period (2 '/z month grace period) The Plan X shall _ shall not be subject to the terms and conditions of Section 15.16 Claims Extension Period. 11. Flexible Benefit Dollars: NOT APPLICABLE The level of Flexible Benefits (Credits/Dollars) that a Participant will receive per year is _ (i.e., annual amount). A Participant will be credited with (Credits/Dollars) on a (pay period, annual) basis. If excess Flexible Benefit Dollar amounts remain at the end of the Plan Year, after all benefits and expenses have been paid by the Plan pursuant to an Employee's election, such excess amounts shall be -forfeited to the Employer or -returned to all Participants in a nondiscriminatory manner in the form of additional compensation (which is subject to applicable withholding and employment taxes). 12. Expense Allocation and Order of Benefit Payments: If the Employer sponsors a Healthcare Flexible Spending Account in addition to a Health Savings Account for Eligible Employees: _ Eligible Medical Expenses (for vision or dental coverage only as defined under Code Section 223(c)) for each Eligible Employee are paid under the Healthcare Flexible Spending Account before or commensurate with the Health Savings Account; _ Eligible Medical Expenses for each Eligible Employee will be paid under the Healthcare Flexible Spending Account, but only after the Health Savings Account; 13. Affiliated Employers: The following Employers have adopted this Plan: © 2009 BMS LLC Page 3 of 4 14. Authorized Signatures: Date ~~'~~ ~P ~~~ Company Name Date Affiliated Employer Date Affiliated Employer By Authorized Signature By By Authorized Signature Authorized Signature ©2009 BMS LLC Page 4 of 4 6EN EFfT MAH KF_TfNG SOLU TIONSµ~ Shipping: 10000 Shelbyville Road, Suite 110, Louisville, KY 40223 Mailing: P.O. Box 43653, Louisville, KY 40253-0653 (502) 244-i16i FAX (502) 244-1162 www.bmsNc.net Flexible Benefits Plan Corporate Resolution Employer Name: City of Jeffersonville Plan Year: January 1, 2009 to December 31, 2009 Certificate of Corporate Resolution The undersigned Secretary or Principal of Cit~of Jeffersonville (the Employer) hereby certifies that the following resolutions were duly adopted by the Employer on and that such resolutions have not been modified or rescinded as of the date hereof: RESOLVED, that the form of Flexible Benefits Plan including any applicable Dependent Care Assistance Program, Healthcare Flexible Spending Account Plan, Adoption Assistance Program, Tax- Free Transportation Program, and/or Health Savings Account, effective January 1, 2009 ,presented to this meeting is hereby approved and adopted and that the duly authorized agents of the Employer are hereby authorized and directed to execute and deliver to the Administrator of the Plan one or more counterparts of the Plan. RESOLVED, that the Administrator shall be instructed to take such actions that are deemed necessary and proper in order to implement the Plan, and to set up adequate accounting and administrative procedures to provide benefits under the Plan. RESOLVED, that the duly authorized agents of the Employer shall act as soon as possible to notify the Employees of the Employer of the adoption of the Flexible Benefits Plan by delivering to each Employee a copy of the summary description of the Plan in the form of the Summary Plan Description presented to this meeting, which form is hereby approved. The undersigned further certifies that attached hereto as Exhibits A and B, respectively, are true copies of the Flexible Benefits Plan and Summary Plan Description approved and adopted in the foregoing resolutions. Secre a y rincipal ~-~~-0 9 Date