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HomeMy WebLinkAboutBMS (2)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: May 1, 2006 to March 31, 2007 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 Jeffe~sonville The Employer shall be the Plan Sponsor and Plan Administrator. 2. Effective Date: X This Flexible Benefits Plan shall be effective as of May 1, 2006. This amended Flexible Benefit~ Plan shall be effective as of If amended and restated, the Plan was originally effective on Plan and Plan Year: The Name of the Plan shall be the C}t¥ of Jeffersonville Flexible Benefits Plan (the "Plan"). The initial Plan Year shall begin on , and end . Future Plan Years will be based on a full twelve-month period beginning each and ending each The initial, short, Plan Year shall begin oni May 1, 2006 , and end on March 31, 2007 Future Plan Years will be based on a full 12-month period beginning each April 1st and ending each March 31st 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 6. Eligible Employees: All Employees shall be eligible to participate in the Plan, except: · Individuals who fail to qualify as an Eligible Individual for a Health Savings Account under Code Section 223(c); · 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 parmership for tax purposes; © 2005 BMS LLC Page 1 of 3 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. Commission 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: 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. X Dependent Care Assistance Program subject to the maximums contained in Section 7.9 of the Plan Document. 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 Group Health Insurance ~ including health insurance, dental and vision insurance. AD&D, etc.); Group Term Life Insurance; Disability Insurance; Tax-Free Transportation Program, subject m 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: © 2005 BMS LLC Page 2 of 3 The contributions for this Plan shall be: X Employee (Salary Redirection) dontributions only; Employer Contributions only, which shall be: $ $ that is convertible to cask compensation; or __ Both Employee (Salary Redirection) and Employer Contributions. annually per Participant of which 10. Claims Extension Period The Plan. X shall shall not be subject to the temps and conditions of Section 15.16 Claims Extension Period. 11. Flexible Benefit Dollars: 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 [emain 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 ~retumed 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; If the Employer sponsors a Health Reimbursement Arrangemem ["HRA"), in addition ro a Health Savings Account, Eligible Medical Expenses under the HRA shall: [] only include expense payments for vision and/or dental coverage, which can be paid before or commensurate with the Health Savings Accounl (but based on the ordering rules of the HRA Plan if a Healthcare Flexible Spending Account is also provided); or [] be paid after the Health Savings Account. 12. Affiliated Employers: The following Employers have adopted this Plan: 13. Authorized S~natures: ate t Company Name Date Affiliated Employer By By  ~Aut~h~r~ed Signature / Authorized Signature Authorized Signature Date Affiliated Employer By © 2005 BMS LLC Page 3 of 3