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HomeMy WebLinkAboutICMA-RC RHS PLAN ADOPTION AGREEMENT (3)h'df1MANICi =. M FII_t WORK MAY PROCEED UNTIL INSURANCE EXPIRE A- 2011- 258 -03 DATE. z 15 OUNC'EMPLOYER VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PLAN ADOPTION AGREEMENT Plan Number: S 03237 s� Q1 Select as applicable: ❑ Standalone RHS ❑ Integrated RHS El Amendment to Existing Plan ❑ New Plan (see NOTE below) NOTE: (For existing employers only): Check here © if you want ICMA -RC to use existing plan contact information for this new plan setup. Otherwise, if contact information has changed, please complete and return the Implementation Data Form found on pg. II:31 along with the adoption materials. Employer Retirement Health Savings Plan Name: I. Employer Name: City of Santa Ana State: CA d 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. 11I. Effective Date of the Plan: 01/01/2016 $ 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 SeneSts Plan - o 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 Safety Employees — Firefighters ❑ General Employees K Collectively- Bargained Employees (Specify unit(s)) Police Management Association, Santa Ana Management Association, V1 Oilier (specify group(s)) Confidential Association of the City of Santa Ana & Full Time and Part Time Civil Service Employees recognized by the Santa Ana City Employees, Chapter 1939 /Service Employees International Union Local 721 (SEIU) 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 of part a non - collectively bargained, self-insured plan, the nondiscrimination requirements of Internal Revenue Code' (IRC) Section 105(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 mules with appropriate counsel. C. Participant Eligibility Requirements 1.. Minimum service: -the minimum period of service required for participation is N/A (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). VI. Contribution Sources and Amounts A. Definition of Earnings The definition of Earnings will apply to all RHS Contribution Features that reference "Earnings ", including Direct Employer Contributions (Section VI.B.1.) and Mandatory Employee Compensation Contributions (Section VI,13.2.). 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 0 Other (describe): See Attached 2. Mandatory Employee Compensation Contributions The Employer will make mandatory contributions of Employee compensation as follows: Reduction in Salary - see ntt.rned % 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 0 Other (specify type of leave) Accrued Leave See Attached An Employee shall not have the right to discontinue or vary the rate of mandatory leave contributions. C. Limits on Total Contributions (check one box) The total contribution by the Employer on behalf of each Participant (including Direct 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.1.: 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 includes a separation from service component and is further defined by (check one): ■ 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 Upon separation from the service of the Employer prior to attainment of benefit eligibility (as outlined in Section IX), or upon reversion to the 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 Contributions for the next and succeeding contribution cycle(s). En 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 B. Termination prior to general benefit eligibility: In case where the general benefit eligibility as outlined in Section IX.A includes a retirement component, a Participant who separates from service of the Employer prior to retirement will be eligible to receive benefits: m Immediately upon separation from service ❑ Other C. A Participant that becomes totally and permanently disabled ❑ as defined by the Social Security Administration WQ as defined by the Employer's primary retirement plan ❑ other will become immediately eligible to receive medical benefit payments from his /her VantageCare Retirement Health Savings Plan account. D. Upon the death of the Participant, benefits shall become payable as outlined in Section XI. X. Permissible Medical Benefit Payments Benefits eligible for reimbursement consist of: ® All Medical Expenses eligible under IRC Section 213* other than (i) direct long -term care expenses, and (ii) expenses for medicines or drugs which are not prescribed drugs (other than insulin). ❑ The following Medical Expenses eligible under IRC Section 213* other than (i) direct long -term care expenses, and (ii) expenses for medicines or drugs which are not prescribed drugs (other than insulin). 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 ofnondiscrimination 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 Dreyfus Cash Management fund* (or another fund selected by the Employer). The account balance may be reallocated by the surviving spouse or dependents. *An investment in the Dreyfus Cash Management money market fund is not insured orguaranteed by the Federal Deposit Insurance Corporation or any othergovernment agency. Although the fund seeks to preserve the value ofyour investment m $1.00 per share, it is possible to lose money by investing in the fund Investors should consider the investment objectives, risks, charges, and expenses ofthe fund carefully before investing. You may visit us at www.icmarc.org or call 800- 669 -7400 to obtain aprospectus that contains this and other information about the fund. Read the prospectus carefully before investing. If a Participant's account balance has not been fully utilized upon the death of the eligible spouse, the account balance may continue to be utilized to pay benefits of eligible dependents. Upon the death of all eligible dependents, the account will revert to the Plan to be 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. Assigunnsnt of benefits is not permltrad. Benefits will be paid only to the Participant, his /her Survivors, the Employer, or an insurance provider (as al loved by the claims ado Inistraror). Payments to an till rd -party payee (e.g., medical service provider) are not permitted with rite exception of reimbursement to the Employer or insurance provider (as allowed by the claims administrator). D. An eligible dependent is (a) the Pirricipait t:s lawfitI spouse, (b) die Participants child under the age of 27, as defined by IRC Section 152(0(1) and Ine run I Revenge Sery ice Notice 2910 -38, or (c) any other individual who is a person described in IRC Section 152(x), as clarified by Internal Revenue Service Notice 2004-79. E. The Employer will be responsible for withholding, reporting and remitting any applicable taxes her payments which are deemed to be discriminatory under IRC Section 105(h), as outlined in the VantageCare I2erirenrent ]-Yeah, Savings Plan Employer Manual. X111. Employer Acknowledgements A. Tlie'Employer hereby acknowledges it understands chat failure to properly fill our this Employer VanrageCare Retirement Health Savings Plan Adoption Agreement mar result in the loss of tax exemption of the Trust and /or loss of rnx def rred status for Employer con [ributons. B. 0 Check this box if you are including supporting documents that include plan provisions. EMPLOYERSI B _. Date. 'title: City Manager Attest. Date: Clerk of the Council Accepted: VANTAGEPOINTTRANSFERAGENtS, LLC } t )Jf n Assistant ilecretary, tCt41r4RC A TESTO MARIAD. HUrI ZARC �j�CIL CLERK P' u 2Q13 APPROVED AS TO FOILAI Laura A. Rossini Senior Assistant CityAttornc•. City of Santa Ana RHS Plan #803237 Amended 1/1/2016 Eligible Group: Police Management Association (PMA) V1.B.1. 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 VI.B.2. Mandatory Employee Compensation Contributions: A percent of earnings as defined by the MOU VI.B.3. 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 1.990 who separate from service on or afterluly 1, 2011 will contribute 100% of holiday leave payout and 100% of management leave payout Eligible Group: Santa Ana Management Association (SAMA) & Confidential Association of the City of Santa Ana (CASA) VI.B.1. 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 SAMA & CASA Medical Retirement Subsidy Plan VI.B.2. Mandatory Employee Compensation Contributions: A percent of earnings as defined by the MOU VI.B.3. Mandatory Employee Leave Contribution: Accrued Sick Leave: Employees who separate from service on or after July 1, 2014 will contribute 100% of eligible sick leave payout City of Santa Ana RHS Plan #803237 Amended 1/1/2016 Page 2 Eligible Group: Full Time (FT) and Part Time Civil Service (PTCS) Employees recognized by the Santa Ana City Employees, Chapter 1939 /Service Employees International Union Local 721 (SEIU). VI.B.1. 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 SEW Medical Retirement Subsidy Plan VI.B.2. Mandatory Employee Compensation Contributions: A percent of earnings as defined by the MOU VI.B.3. Mandatory Employee Leave Contribution: Accrued Sick Leave: Employees who separate from service on or after November 17, 2015 will contribute 100% of eligible sick leave payout CER_T_IFI_CAT_E - -F LIABILITY INS- U- RANGE DATE(MMI °° YYY, 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. CONTACT NAME' WASHINGTON, CUT AVENUE, SUITE 700 WASHINGTON, DC 20036 -5386 PHONE FAX c No ac No : E -MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC 9 040356- FINPR- EO,fl -15 -16 INSURER A: Phoenix Insurance Company 25623 INSURED ICNIA RETIREMENT CORP, INSURER B: NIA - N/A INSURER C: Travelers Casualty Insurance Co. Of America 19046 ATTN: D'JUANA THOMAS 777 HINGTO ,DC 2 002 NE WASHINGTON, DC 20002 INSURER D: Federal Insurance Company 20281 INSURER E: SL Paul Fire 8 Marine Insurance Co. 24787 X INSURER F: $ 10,000 ' -' ���.Ywwry rvVIYIOCR:e 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 UBR ylya POLICY NUMBER POLICY EFF MMIDD/YYVV POLICY E %P MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY F-1-1 OCCUR CLAIMS -MADE CONTRACTUAL COV. INCL. 6306E588375 O 7l� 0810112015 08101/2016 EACH OCCURRENCE $ 1,000,000 PREMISES R a occurrence $ 1,000,000 X MED EXP (Any one person) $ 10,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY 0 PRO- ❑ LOC JECT OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP /OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON HIRED AUTOS AUTOS OWNED AUTOS t 'q 6 .L J r't COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Par accident) $ Pe,,,IdYDAMAGE Per accitleM $ C UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS MADE IA U8650BM894 08/01/2015 08101/2016 EACH OCCURRENCE $ AGGREGATE $ OED RETENTION$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR /PARTNER /EXECUTIVE IM OFFICEREMBER EXCLUDED? M (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below X PER 0TH- STATUTE ER $ EL EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYE $ 1,00 0,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 D E BANKERS PROF. LIAB. SIR: $1,000,000 8211 -6261 ZPL- 71M07549 -15 -N2 06130/2015 06/30/2015 0613012016 06/3012016 $7,500,000 plo $12,500,000 15,000,000 pi $12,500,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may he attached If more space is required) 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. Manashi Mukherjee �.,. _z © 1988 -2n14 ACORn CORP17)RATlr1n1 All . ;..r.._ ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD V elz•111 5 AGENCY CUSTOMER ID: 040356 LOC #: Washington ACOR °® L ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMEDINSURED MARSH USA INC. ICMA RETIREMENT CORP. ATTN: D'JUANA THOMAS 777 NORTH CAPITOL ST., HE POLICY NUMBER WASHINGTON, DC 20002 CARRIER NAIC CODE EFFECTIVE DATE: 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 E FF /EXP: 06130/2015 - 06/30/2016 LIMIT: $25,000,000 DED: $250,000 ACORD 101 (2008101 ) © 2008 ACORD CORPORATION. All rights reserved fhe ACORD name and logo are registered marks of ACORD AC., L/Af.J CERTIFICATE—OF LIABILITY—INSURANCE LIf' BI I- DATE(MMIDDIYYYY) -L—IT — I�Vd- IJiFAI-Y -b -E �.... -�' o713112015 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. 1050 CONNECTICUT AVENUE, SUITE700 WASHINGTON, DC 20036 -5386 CONTACT NAME: PHGNE. Extl FAX No: E -MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAICq 040356 - FINPR- EO.FI.15 -16 INSURER A: Phoenix Insurance Company 25623 INSURED ICMA RETIREMENT CORK _INSURERS: NIA NIA INSURER C: Travelers Casualty Insurance Co. Of America 19046 ATTN: D'JUANA THOMAS 777 NORTH CAPITOL ST., NE WASHINGTON, DC 20002 _INSURER D: Federal Insurance Company pppgl INSURER E: St. Paul Fire & Marine Insurance Co. pg767 INSURER F: $ 1,000,000 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 TYPEOF INSURANCE AODL SUBR POLICY NUMBER POLICY EFF IMMIDDNYYYt POLICY EXP (MMIDDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR CONTRACTUALCOV.INCL 6306E588375 0810112015 OBI01I2016 EACH OCC URRENCE $ 1,000,000 DAMAGES Rz, cc rr PREMISES Ea occurrence $ 1,000,000 X MED EXP(Any one person) $ 10,000 $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER X PRO - POLICY JECT LOC. GENERAL AGGREGATE GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMPIOP AGO $ 2,000,000 $ OTHER'. AUTOMOBILE LIABILITY �� COMBINEDSINGLE LIMIT (Ease cden $ BODILY INJURY (Per person) $ ANY AUTO1 ALL OWNED SCHEDULED AUTOS AUTOS $ BODILY INJURY (Per accident) $ HIRED AUTOS NED AUTOS AUTOS PROPERTYDAMAGE Per accitlenl $ UMBRELLA LIAR OCCUR RRENCE $ E $ EXCESS LIAR CLAIMS -MADE DIED RETENTION$ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR /PARTNER /EXECUTIVE FN OFFICERIMEMBER EXCLUDED? 1A UB6508M894 0810112015 0810112016 OTH- E ER WPOLICY CCIDENT $ 1,000,000 -EA EMPLOYEE 1,000,000 If yes describe toryin and If yes,ate, in under - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below D BANKERS PROF. LIA3 . 8211 -5261 0613012015 0613012016 $7,500,000 plo $12,500,000 E SIR: $1,000,000 ZPL -71 M07549-15 -N2 0613012015 0 6I3012016 $5,000,000 pIo $12,500,000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CITY OF SANTA ANA ATTN: EXECUTIVE DIRECTOR OF PERSONNEL SVS 20 CIVIC CENTER PLAZA V34 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. Masashi Mukherlee ��­r Q9 1Ut3t3-ZU14 ACUKU CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD _ ( J Lq AGENCY CUSTOMER ID: 040356 LOC #: Washin Ac ®R"® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMEDINSURED MARSH USA INC. ICMA RETIREMENT CORP. ATTN. PJUANA THOMAS 777 NORTH CAPITOL ST., NE POLICY NUMBER WASHINGTON, DC 20002 CARRIER NAIC CODE EFFECTIVE DATE: 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 EFF /EXP, 06/3012015- 06/3012016 LIMIT: $25,000,000 DEC $250,000 ^""• "' • °•�� ° ° °• °'/ v NUU AIUKU UUKYUKA I IVN. All rights reserved. The ACORD name and logo are registered marks of ACORD