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HomeMy WebLinkAboutICMA-RC RHS PLAN ADOPTION AGREEMENT7 JY _ iNGURANGi: )iv r-ii, NORK MAY F'ROC ,zE UN TI �- AT ICM/RC Building Retirement Senu ity EMPLOYER VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PLAN ADOPTION AGREEMENT A- 2011- 258 -01 EMPLOYER VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PLAN ADOPTION AGREEMENT Plan Number: 8 03237 Employer Retirement Health Savings Plan Name: I. Employer Name: City of Santa Ana Check one: ❑ New Plan m Amendment to Existing Plan State: CA II. The Employer hereby attests that it is a unit of a state or local government or an agency or instrumentality of one or more units of a state or local government. III. Effective Date of the Plan: March 1, 2012 IV. The Employer intends to utilize the Trust to fund only welfare benefits pursuant to the following welfare benefit plan(s) established by the Employer: City of Santa Ana Retiree Welfare Benefits Plan V. Eligible Groups, Participation and Participant Eligibility Requirements A. Eligible Groups The following group or groups of Employees are eligible to participate in the VantageCare Retirement Health Savings Plan (check all applicable boxes): ❑ All Employees ❑ All Full -Time Employees ❑ Non -Union Employees ❑ Public Safety Employees — Police ❑ Public Safer), Employees — Firefighters ❑ General Employees ® Collectively - Bargained Employees (Specify unit(s)) ❑ Other (specify group(s)) Police Management Association, Fire Management Association The Employee group(s) specified must correspond to a group(s) of the same designation that is defined in the statutes, ordinances, rules, regulations, personnel manuals or other documents or provisions in effect in the state or locality of the Employer. B. Participation Mandatory Participation: All Employees in the covered group(s) are required to participate in the Plan and shall receive contributions pursuant to Section VI. If the Employer's underlying welfare benefit plan or funding under this VantageCare Retirement Health Savings Plan is in whole or part a non - collectively bargained, self- insured plan, the nondiscrimination requirements of Internal Revenue Code (IRC) Section I05(h) will apply. These rules may impose taxation on the benefits received by highly compensated individuals if the Plan discriminates in favor of highly compensated individuals in terms of eligibility or benefits: The Employer should discuss these rules with appropriate counsel. C. Participant Eligibility Requirements Minimum service: The rninimum period of service required for parri(iparion is NSA (write N/A if no minimum service is required). 2 Minimum age: The minimum age required for eligibility to participate is N/A (write N/A if no minimum age is required). N V1. Contribution Sources and Amounts A. Definition of Earnings The definition of Earnings will apply to all RI IS Contribution Features that reference `Earnings ", including Direct Employer Contributions (Section VI.B.1.) and Mandatory Employee Compensation Contributions (Section VI.B.2.). Definition of earnings: AS defined by the MOU B. Direct Employer Contributions and Mandatory Contributions 1. Direct Employer Contributions The Employer shall contribute on behalf of each Participant ❑ % of Earnings ❑ $ each Plan Year ❑ A discretionary amount to be determined each Plan Year Q Other (describe): See Attached 2. Mandatory Employee Compensation Contributions The Employer will make mandatory contributions of Employee compensation as follows: ® Reduction in Salary - See Attached % of Earnings or $ will be contributed for the Plan Year. ❑ Decreased Merit or Pay Plan Adjustment - All or a portion of the Employees' annual merit or pay plan adjustment will be contributed as follows: An Employee shall not have the right to discontinue or vary the rate of Mandatory Contributions of Employee Compensation. 3. Mandatory Employee Leave Contributions The Employer will make mandatory contributions of accrued leave as follows (provide formula for determining Mandatory Employee Leave contributions): ® Accrued Sick Leave See attached ® Accrued Vacation Leave See attached ❑ Other (specify type of leave) Accrued Leave See attached ,-\n F111ployee ~hall not have the right to discontinue or vary= the rare of mandatory leave contributions. C. Limits on Total Contributions (check one box) 11,e total contribution by the Employer on behalf of each Participant (including I )irect Employer and Mandatory Employee Contributions) for each Plan Year shall not exceed the following limit(s) below. Limits on individual contribution types are defined within the appropriate section above. ❑ There is no Plan - defined limit on the percentage or dollar amount of earnings that may be contributed. ❑ % of earnings* *Definition of earnings: ❑ Same as Section VI.A.. ❑ Other ❑ $ for the Plan year. See Section V.B. for a discussion of nondiscrimination rules that may apply to non - collectively bargained self - insured Plans. VII. Vesting for Direct Employer Contributions A. Vesting Schedule (check one box) ® The account is 100% vested at all times. ❑ The following vesting schedule shall apply to Direct Employer Contributions as outlined in Section VI.B. I.: Years of Service Vesting Completed Percentage % % B. The account will become 100% vested upon the death, disability, retirement *, or attainment of benefit eligibility (as outlined in Section IX) by a Participant. *Definition of retirement (check one box): ❑ Retirement as defined in the primary retirement plan of the Employer ❑ Separation from service ❑ Other C. Any period of service by a Participant prior to a rehire of the Participant by the Employer shall not count toward the vesting schedule outlined in A above. VIII. Forfeiture Provisions t'pon separation from the service of the Employer prior to attainment of benefir eligibility (as outlined in Section IV or upon reversion r o t he Trust of a Participant's account assets remaining upon the participant's death (as outlined in Section XI), a Participant's non - vested funds shall (check one box): ❑ Remain in the Trust to be reallocated among all remaining Employees participating in the Plan as Direct Employer (:ontributions for the next and succeeding contribution cycle(s). 0 Remain in the Trust to be reallocated on an equal dollar basis among all Plan Participants. ❑ Remain in the Trust to be reallocated among all Plan Participants based upon Participant account balances. ❑ Revert to the Employer. IX. Eligibility Requirements to Receive Medical Benefit Payments from the VantageCare Retirement Health Savings Plan A. A Participant is eligible to receive benefits: ❑ At retirement only (also complete Section B.) Definition of retirement: ❑ Same as Section VILB. ❑ Other ❑ At separation from service with the following restrictions ® No restrictions Other ❑ At age only ❑ At retirement and age Definition of retirement: ❑ Same as Section VILB. ❑ Other ❑ At retirement or age Definition of retirement: ❑ Same as Section VILB. ❑ Other (also complete section B) ❑ Other, specified as follows (also complete Section B if applicable): B. Termination prior to general benefit eligibility: In the case where the general benefit eligibility as outlined in Section IX.A includes a retirement component, a Participant who separates from the service of the Employer prior to retirement will be eligible to receive benefits: QImmediately upon separation from service. ❑ At age C. A Participant that becomes totally and permanently disabled ❑ as defined by the Social Security Administration ® as defined by the Employer's primary retirernent plan ❑ other will bcconic immediately eligible to receive medical benefit payment~ from hislher Vantagc( :arc Rcirctnent Health Savings Plan account. l)- I'pon the death of rhr Participant- benefits shall become payable as onrlincd in Section al. X. Permissible Medical Benefit Payments Benefits eligible for reimbursement consist of: Q All Medical Expenses eligible under IRC Section 213* other than direct long -term care expenses, and including non - prescription medications allowed under IRS guidance. ❑ The following Medical Expenses (select only the expenses you wish to cover under the VantageCare Retirement Health Savings Plan): ❑ Medical Insurance Premiums ❑ Medical Out -of- Pocket Expenses* ❑ Medicare Part B Insurance Premiums ❑ Medicare Part D Insurance Premiums ❑ Medicare Supplemental Insurance Premiums ❑ Prescription Drug Insurance Premiums ❑ COBRA Insurance Premiums ❑ Dental Insurance Premiums ❑ Dental Out -of- Pocket Expenses* ❑ Vision Insurance Premiums ❑ Vision Out -of- Pocket Expenses* ❑ Qualified Long -Term Care Insurance Premiums ❑ Non - Prescription medications allowed under IRS guidance* ❑ Other qualifying medical expenses (describe)* * See Section V.A. for a discussion of nondiscrimination rules which may apply to non - collectively bargained, self - insured Plans. XI. Benefits After the Death of the Participant In the event of a Participant's death, the following shall apply: A. Surviving Spouse and /or Surviving Dependents The surviving spouse and /or surviving eligible dependents (as defined in Section XII.D.) of the deceased Participant are immediately eligible to maintain the account and utilize it to fund eligible medical benefits specified in Section X above. Upon notification of a Participant's death, the Participant's account balance will be transferred into the Vantagepoint Money Market Fund` (or another fund selected by the Employer). The account balance may be reallocated by the surviving spouse or dependents. 'Please read the current Vantagepoint Rlutual Funds prospectus carefully prier to investing. An investrnent in this fisnd is neither insured norguaranteed and there can be no assurance that the Fund ivill be able to maintain a stable net asset value of SI.00 per share. Vantagepoint Mutual Funds are distributed by ICAIA- RCServices, LTC, a wholly -named broker- dealer affiliate of7CAIA Retirement Corporation. Member FINRAISIPC. If a Participant's account balance ha, not been fully utilized upon the death of the eligible spouse, the account balance mgv continue to be utilized to pay benefits of eligible dependents. Upon the death of all eligible dependents, the account will revert to the flan to he applied as specified in Section VIII. B. No Surviving Spouse or Surviving Dependents If there are no living spouse or dependents at the time of death of the Participant, the account will revert to the Plan to be applied as specified in Section VIII. XII. The Plan will operate according to the following provisions: A. Employer Responsibilities 1. The Employer will submit all VantageCare Retirement Health Savings Plan contribution data via electronic submission. 2. The Employer will submit all VantageCare Retirement Health Savings Plan Participant status updates or personal information updates via electronic submission. This includes but is not limited to termination notification and benefit eligibility notification. B. Participant account administration and asset -based fees will be paid through the redemption of Participant account shares, unless agreed upon otherwise in the Administrative Services Agreement. C. Assignment of benefits is not permitted. Benefits will be paid only to the Participant, his /her Survivors, the Employer, or an insurance provider (as allowed by the claims administrator). Payments to an third -party payee (e.g., medical service provider) are not permitted with the exception of reimbursement to the Employer or insurance provider (as allowed by the claims administrator). D. An eligible dependent is the Participant's lawful spouse and any other individual who is a person described in IRC Section 152(a), as clarified by Internal Revenue Service Notice 2004 -79. E. The Employer will be responsible for withholding, reporting and remitting any applicable taxes for payments which are deemed to be discriminatory under IRC Section 105(h), as outlined in the VantageCare Retirement Health Savings Plan Employer Manual. XIII. Employer Acknowledgements A. The Employer hereby acknowledges it understands that failure to properly fill out this Employer VantageCare Retirement Health Savings Plan Adoption Agreement may result in the loss of tax exemption of the Trust and /or loss of tax- deferred status for Employer contributions. B. © ( ,heck this box if you are including supporting documents that include plan provisions. EMPLOYER SIGNATURE By: �` �� x - — Date: /�� (2y Tit Y "City Manager Attest: Title: Accepted: VAN l'A(;EPOINT TRANSFER AGENTS, LLC -. f Assistant Srcrctan 1(.N- I.A -RC Date: APPROVED AS TO FORM LISA E. STORCK Assistant City Attorney ATTEST: MARIA D. HUIZAR✓ CLERK OF THE COUNCIL MR 1 5 2412 City of Santa Ana RHS Plan #803237 Eligible Group: Police Management Association Direct Employer Contribution: 1. A percent of earnings as defined by the MOU 2. A one -time lump sum contribution as a conversion from the existing PMA Medical Retirement Subsidy Plan Mandatory Employee Contribution from Compensation: A percent of earnings as defined by the MOU Mandatory Employee Leave Contribution: Accrued Sick Leave: Employees hired prior to 1990 who separate from service on or after July 1, 2011 will contribute 100% of eligible sick leave payout Accrued Vacation Leave: Employees hired prior to 1990 who separate from service on or after July 1, 2011 will contribute 100% of vacation leave payout Accrued Management Leave and Holiday Pay: Employees hired prior to 1990 who separate from service on or after July 1, 2011 will contribute 100% of holiday leave payout and 100% of management leave payout Eligible Group: Fire Management Association Direct Employer Contribution: A one -time lump sum contribution as a conversion from the existing FMA Medical Retirement Subsidy ACQ ° CERTIFICATE OF LIABILITY INSURANCE " I TYPE OF INSURANCE 2o'°DNYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER MARSH USA INC. SUITE 400 1255 23RD STREET, N.W. WASHINGTON, DC 20037 CONTACT NAME: PNONE FAX Extl, Nol: E- MALI ADDRESS: INSURERS AFFORDING COVERAGE NAIC 0 040356- Bond.- E0+FI-11 -12 INSURER A: St. Paul Protective Insurance Company 19224 _ _ INSURED ICMA RETIREMENT CORP. INSURER B : Federal Insurance Company 20281 _ INSURER C: St. Paul Fire & Marine Ins Co _ 24767 ATTN: BARBARA STOTLER 777 NORTH CAPITOL N.E. WASHINGTON, DC 200000 2 INSURER D : Standard Fin; Insurance Company 18070 INSURER E; Great American Insurance Co. _ 16691 $ 1,000,000 INSURER F : GENERAL AGGREGATE %.vvr_rwuw CERTIFICATE NUM13ER- r.1E_n0q7A31 ')dn1 ncvlcrnr.r sur■m0n.. vrvl• r�Ym�GR.'r THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR I TYPE OF INSURANCE SUBR POLICY NUMBER MMIDDY Y MPOLICY /YYYY - - -- LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR CONTRACTUAL COV. INCL. FS06805895 AyS gC VED 08/01/2011 X1/1 ~ F 06!01!2012 EACH OCCURRENCE $ 1,000,000 (Ea occurrence) $ 1'000'000 MED EXP (Any one person) $ 10,000 X PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO- 1 LOC PRODUCTS - COMP /OP AGG $ 2,000,000 $ — AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS _ AUTOS NON-OWNED HIRED AUTOS �`gp E• ST A Assistant C y RCK �Orney { �. COMBINED SINGLE LIMIT Ea dent BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident) $ $ D UMBRELLA LU1B EXCESS LIAB L- OCCUR CLAIMS -MADE I N / A UB- 6508M80 -4 -11 0810112011 08/01/2012 EACH OCCURRENCE $ _ AGGREGATE $ —N DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN I ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERWEMBER EXCLUDED? E I Mandatory In NH) If I Dyes, d escribe under DESCRIPTION OF OPERATIONS below WC STATU- OTH- $ $ 1,�0,� E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 B C BANKERS PROF. LIAB. BANKERS PROF. LIAB, 8211 -6261 ECO9004016 04/1912011 04/19/2011 04/19/2012 04/19/2012 LIMIT 17,500,000 SIR 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS f VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CFRTICICATC uAl nen CITY OF SANTA ANA ATTN: EXECUTIVE DIRECTOR OF PERSONNEL SVS 20 CIVIC CENTER PLAZA M -34 SANTA ANA, CA 92702 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Timothy M. Sasser r a00-4V IV M%,UKU 1i;U11rURATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ACOR AGENCY MARSH USA INC. POUCYNUMBER AGENCY CUSTOMER ID: 040356 LOC #: Washington ADDITIONAL REMARKS SCHEDULE NAMEDINSURED ICMA RETIREMENT CORP. ATTN: BARBARA STOTLER 777 NORTH CAPITOL ST., N.E. WASHINGTON, DC 20002 CARRIER NAIC CODE EFFECTIVE DATE: Page 2 of 2 w cwo r,wKU LoUKFURATION. All rights reserved. The ACORD name and logo are registered marks of ACORD / -' i V �1 - t.1 it ./_A t f� os'o 0 AC40RO CERTIFICATE OF LIABILITY INSURANCE DATE (MWDD/YYYY) 071310012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER MARSH USA INC. SUITE 400 1255 23RD STREET, N.W. WASHINGTON, DC 20037 CONTACT NAME: PHONE FAX AAIC. No. ExII)e I (A/C, No): E-MAIDR L ADESS: INSURER (S) AFFORDING COVERAGE NAIC R INSURER A: St. Paul Protective Insurance Company 19224 040356-- EO +FI -12 -13 INSURED ICMA RETIREMENT CORP. ATTN: BARBARA STOTLER INSURER B: Federal Insurance Company 20281 INSURER C: St. Paul Fire & Marine Ins Co 24767 INSURER 0: Standard Fire Insurance Company 19070 777 NORTH CAPITOL ST., N.E. WASHINGTON, DC 20002 INSURER E: Great American Insurance Co. 16691 INSURER F: GE T AGGREGATE LIMIT APPLIES PER: X i POLICY F1 PRO- LOC PRODUCTS - COMP /OP AGG COVERAGES CERTIFICATE NUMBER: CLE- 003743124 -08 REVISION NUMBER:5 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE. POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/VYYY POLICY EXP MMIDD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fq OCCUR X CONTRACTUAL COV. INCL. of Marsh USA Inc. ZLP10S82630 08/01/2012 08/01/2013 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 1,000,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE T AGGREGATE LIMIT APPLIES PER: X i POLICY F1 PRO- LOC PRODUCTS - COMP /OP AGG $ 2,000,000 $ AUTOMOBILE LiA6iLITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS pp Ay i rO A, �: 4 (1' 3()� -,, �a o �y COMBINED SINGLE LIMIT Ea accident! BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ rD UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE A$Slbta12L EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER /MEMBER EXCLUDED? F`N] (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA UB- 6508M89-4 -12 08/01/2012 08/01/2013 X WCSTATU- 0TH- E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 $ B C BANKERS PROF. LIAB. BANKERS PROF. LIAB. 8211 -6261 14RN20360 04119/2012 04/1912012 04/19/2013 04/19/2013 LIMIT 17,500,000 SIR 1,000,000 DESCRIPTION OF OPERATIONS! LOCATIONS/ VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION CITY OF SANTA ANA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN: EXECUTIVE DIRECTOR OF PERSONNEL SVS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 20 CIVIC CENTER PLAZA M -34 ACCORDANCE WITH THE POLICY PROVISIONS. SANTA ANA, CA 92702 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ®1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 040356 LOC #: Washington Atc R/ ADDITIONAL REMARKS SCHEDULE V NAMED INSURED AGENCY ICMA RETIREMENT CORP. MARSH USA INC. ATTN: BARBARA STOTLER 777 NORTH CAPITOL ST., N.E. POLICY NUMBER WASHINGTON, DC 20002 CARRIER NAIC CODE EFFECTIVE DATE: Page 2 of 2 ACORD 101 (20M01) %w � %pww - - -- - -- The ACORD name and logo are registered marks of ACORD moll -X58- 01 7C CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 0713112615 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: N the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER MARSH USA INC. 1050 CONNECTICUT AVENUE, SUITE 700 WASHINGTON, DC 20036 -5386 CONTACT NAME: _ PHONE (AX AIC NoL _ _ __ __ E -MAIL _ ADDRESS: INSURERS) AFFORDING COVERAGE _ _ NAICN _ INSURER A: Phoenix Insurance Company 25623 040356 - FINPR- EO+FI-15A6 _ — INSURED ICMA RETIREMENT CORP. ATTN: D'JUANATHOMAS 777 NORTH CAPITOL ST., NE INSURER B :NIA _ NIA Travelers Casualty Insurance Co. Of Amence INSURER C: 8Y 19046 _ _ INSURER D : Federal Insurance Company 20281 INSURER E: St. Paul Fire 8 Marine Insurance Co. -_ 24767 WASHINGTON, DC 20002 _ INSURER F: PERSONAL & ADV INJURY $ 1.000,000 ,IUN NUMCCK:o THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTk TYPEOFINSURANCE AUOL SUER POLICY NUMBER POLICY EFF MMIDO/YYYY POLICY EXP MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1 OCCUR CONTRACTUAL COV. INCL. of Marsh USA Inc. 6306E588375 0810112015 0810112016 EACH OCCURRENCE _ $ _1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 1,000,000 X MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1.000,000 GEN•L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2.000.000 PRODUCTS - COMPIOP AGG $ 2,000,000 X POLICY F1 JECT LOC OTHER. AUTOMOBILE LIABILITY ^n� COMBINED SINGLE LIMIT Ea accitlem $ _ BODILY INJURY (Per person) $ ANY AUTO •d-- BODILY INJURY (Per accdem) $ ALL OV•MED SCHEDULED AUTOS AUTOS NON- OVeMED HIRED AUTOS AUTOS t) h� o PROPERTY DAMAGE Per accoent $ - $ — UMBRELLA LU1B OCCUR EACH OCCURRENCE $ _ AGGREGATE _ $ EXCESS LIAe_ CLAIMS MADE DED RETENTION $ $ C WORKERS COMPENSATION UB6508MB94 0810111015 06/0112016 X PER OTH- STATUTE Eft _ AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFHCERIMEMBER EXCLUDED? (Manclarory in NH) NIA E L. EACH ACCIDENT $ 1.000.000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT _ $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS bel. D BANKERS PROF. 1 1 0613012015 0613012016 $7,500,000 plo $12,500,000 E SIR: $1,000,000 ZPL -71 M07549 -15 -N2 0613072015 0613012016 $5,000,000 plo $12,500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attaches! If more space Is required) CAT- HOLDER CANCELLATION CERTIFI CITY OF SANTA ANA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN. EXECUTIVE DIRECTOR OF PERSONNEL SVS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 20 CIVIC CENTER PLAZA Nt_34 ACCORDANCE WITH THE POLICY PROVISIONS. SANTA ANA, CA 92702 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukheljee - sum.- .. -��.° - e�--- >= ^• --8•�- Q TyeD-20l4 AWRY MVnr-vi� . rvn. nn nyu ,vav,.vv. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 040356 LOCfl: Washington Ac0 ADDITIONAL REMARKS SCHEDULE Page z of 2 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance FIDELITY BONDICRIME: CARRIER: Great Amencan Insurance Coagany POLICY NO.: FS 234 -6354 EFFIEXP. W302015- 061302016 LIMIT: $25,000,000 DED:$250,000 ACORD 101 12008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are reglstefea marKS Or Awnu NAMED INSURED AGENCY ICMA RETIREMENT CORP. MARSH USA INC. ATTN: UJUANA THOMAS 777 NORTH CAPITOL ST., NE POLICY NUMBER WASHINGTON,DC 20002 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance FIDELITY BONDICRIME: CARRIER: Great Amencan Insurance Coagany POLICY NO.: FS 234 -6354 EFFIEXP. W302015- 061302016 LIMIT: $25,000,000 DED:$250,000 ACORD 101 12008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are reglstefea marKS Or Awnu A.ttrachment 2 SUGGESTED AFFIRMATIVE STATEMENT D®NIA FOR THE VANTAGECARE RETIREMENT HEALTH SAVINGS PLAN AMENDMENT FOR DEFINITION OF SPOUSE Plan Number: 80 3 2 3 7 , 803550, 803551. Name of Employer: City of Santa Ana State: C A WHEREAS, the Employer has established and maintains a retiree health savings plan in the form of the ICMA Retirement Corporation's VanrageCare Retirement Health Savings program, as amended (the "Plan "); WHEREAS, the assets of the Plan are held in trust for the exclusive benefit of Plan participants and their spouses and dependents, and shall not be diverted to any other purpose prior to the satisfaction of all liabilities of the Plan; WHEREAS, die plan has operated in accordance with federal recognition of same -sex spouses; and WHEREAS, an amendment to the Employer's Plan in accordance with the federal recognition of same -sex spouses is adopted to comply with Internal Revenue Service guidance issued in response to the Supreme Court's decision in United States v. Windsor; NOW, THEREFORE BE IT RESOLVED that the Employer hereby amends the Plan to define the term "Spouse" as the Participant's lawful spouse as determined under the laws of the jurisdiction in which the Participant was married. As a duly authorized agent of the above named Employer, I hereby AMEND the Declaration of Trust of the Integral ParrTtusr and Retiree Welfare Benefits documents, as applicable, to include the federal recognition of same -sex spouses. The Plan allows same -sex spouse to receive tax -free reimbursements for all same -sex marriages that are valid as of September 16, 2013, unless the employer specifies an earlier valid date hereof as (Leave blank. Unless wing earlier dare) Name ofAutltorizcd Official (please print): David Cavazos Signature Title: City Manager Date: d S/ o 7, i- o I S7 Monde / Day / Year PROVE S FORM Jose SandoYzA- �)nior Assistant City Attorney Fax to: ICMA -RC AT TN: Workflow Management Team 202 - 682 -6439 ATTEST: -/I AMIOt i MARIA D. HUIZAR CLERK OF THE COUNCIL Mail to: ICiMA -RC OR ATTN: Workflow ManagementTeam P.O. Box 96220 Washington, D.C. 20090 -6220 VANTAGECARE RETIREMENT HEALTH SAVINGS PLAN AMENDMENT DEFINITION OF SPOUSE FOR City of Santa Ana_ (PIAME OF EMPLOYEBj� Attachment 3 DOAL4 City of Santa Ana , as Plan Sponsor, hereby amends its VantageCare Retirement FnIA o OF EMFLOYER) Health Savings Plan by adopting the following revisions to the Plan documents. DECLARATION OF TRUST OF City of Santa Ana INTEGRAL PART TRUST (F TAME OF SwLOYERI ARTICLE 1.1(h) DEFINITION OF "SPOUSE" 1.1(h) "Spouse" means the Participant's lawful spouse as determined under the Taws of dte jurisdiction in which the Participant was married. City of Santa Ana RETIREE WELFARE BENEFITS PLAN fPIAMF OF EMPLOYER ARTICLE 2.11 DEFIiNITION OF "SPOUSE" 2.11 "Spouse' means the Participant's lawful spouse as determined under the laws of the jurisdiction in which the Participant was married. All other defined terms in this plan shall have the tneanings specified in the various Articles of the Plan in which they appear. Fax to: [CN(A -RC ATTN: Workflow Management Team 202 -682 -6439 Mail to: [CIA -RC OR ATTN; WorlcdowrYtanagementTeam P.O. Box 96220 Washington, D.C. 20090 -6220 A � P CERTIFICATE OF LIABILITY INSURANCE GATE m ) 07/051/2016 2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACTyy�}F�rTV�E €N T.F�E IS, SUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. LUIO .? t _ / P_ { : IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A p i ye pn Iii gertjf cafe does not confer rights to the certificate holder in lieu of such endorsement(s). +� 4 r_ ?i. f t � ,(> s =1 is PRODUCER MARSH USA INC. 1050 CONNECTICUT AVENUE, SUITE 700 CONTACT NAME: _ PHONE FAX AIC No: WASHINGTON, DC 20036 -5386 E -MAIL ADORESS: INSURER(S) AFFORDING COVERAGE NAIC 9 6306E588375 e( Iv INSURER A : Phoenix Insurance Company 25623 040356 - FINPR- EO +FI -16 -17 INSURED [CMA RETIREMENT CORP. INSURER B: N/A NIA INSURER c :Travelers Casualty Insurance Co, Of America 19046 TTN: D'JUANA THOMAS ATTN 777 NORTH CAPITOL ST., NE WASHINGTON, DC 20002 INSURER D: Federal Insurance Company 20201 INSURER E: St, Paul Fire & Marine Insurance Co. 24767 INSURER F: $ 2,000,000 - COMP /OP AGG COVERAGES CERTIFICATE NUMBER: CLE- 004640666 -23 REVISION NUMBER:5 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR R TYPE OF INSURANCE ADDL SU O POLICY NUMBER MMIDDY� MMIDDYIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY FVT CLAIMS -MADE OCCUR CONTRACTUAL GOV. INCL. Manashi Mukherjee 6306E588375 e( Iv 00101/2015 ' 08101/2016 RRENCE $ 1,000,000 RENTED Ea occurrence $ 1,000,000 X GEN'L X y one person) $ 10,000 ADV INJURY PTO $ 1,000,000 AGGREGATE LIMIT APPLIES PER: POLICY 0 PRO- ❑ LOC JECT OTHER: GGREGATE $ 2,000,000 - COMP /OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO A O SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS / J+ P % a � I,J I c Y COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CIAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ RED I I RETENTION$ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNEWEXECUTIVE OFFICER /MEMBER EXCLUDED? r (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA UB650SM894 08/01/2015 08/01/2016 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 D E BANKERS PROF. LIAB. SIR: $1,000,000 8211 -6261 ZPL- 71MO7549 -16 -N2 06/30/2016 06/30/2016 06/30017 06/30/2017 $7,500,000 plc $12,500,000 $5,000,000 pIo$12,500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additlonal Remarks Schedule, may be attach ad If more space Is required) CERTIFICATE HOLDER CANCELLATION CITY OF SANTA ANA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN: EXECUTIVE DIRECTOR OF PERSONNEL SVS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 20 CIVIC CENTER PLAZA M -34 ACCORDANCE WITH THE POLICY PROVISIONS. SANTA ANA, CA 92702 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ACORD 25 (2014101) ©1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 040356 _ LOC #: Washington AC"R t ADDITIONAL REMARKS SCHEDULE Page 2 of 2 11i — AGENCY NAMED INSURED MARSH USA INC. OVA RETIREMENT CORP. ATTN: D'JUANA THOMAS 777 NORTH CAPITOL ST., NE POLICY NUMBER WASHINGTON, DC 20002 CARRIER NAIC CODE EFFECTIVE GATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate Of Liability Insurance FIDELITY BOND/CRIME: CARRIER: Great American Insurance Company POLICY NO.: FS 234 -63 -54 EFFIEXP', 06130/2016 - 06/3012017 LIMIT: $25,000,000 DED',$250,000 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NOTICE OF COMPLIANCE Contractor Mission Square Retirement Name: Project A-2011-258-01 Number: Project Employer Vantagecare Retirement Health Savings (RHS) Plan Name: Adoption Agreement The Certificate of Insurance (COI) submitted indicates that the coverages are in compliance with the insurance requirements. No further action is required at this time. The compliant coverage(s) are: EXPIRATION TYPE OF INSURANCE POLICY NUMBER COI DATE FILE NAME DATE MissionSquare Retirement COI BANKERS PROF. LIAB. 82116261 06/30/2023 08/03/2022 Exp 8-1-23 RMD08042022.pdf MissionSquare Retirement COI GENERAL LIABILITY 36044995 08/01/2023 08/03/2022 Exp 8-1-23 RMD08042022.pdf MissionSquare WORKERS COMPENSATION AND EMPLOYERS' Retirement COI 71763685 08/01/2023 08/03/2022 LIABILITY Exp 8-1-23 RMD08042022.pdf Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team