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HomeMy WebLinkAbout25E - AGMT - EMPL BENEFITSREQUEST FOR COUNCIL ACTION CITY COUNCIL MEETING DATE: SEPTEMBER 5, 2017 TITLE: APPROVE EMPLOYEE GROUP INSURANCE RATE RENEWALS WITH CALPERS, DELTA DENTAL, METLIFE DENTAL, EYEMED, AETNA LIFE; APPROVE AGREEMENT WITH REACH EMPLOYEE ASSISTANCE INC; APPROVE AGREEMENT WITH TASC FOR MANAGEMENT OF FLEX SPENDING ACCOUNTS AND RETIREE DENTAL; RECEIVE AND FILE CONTINUED AGREEMENT WITH ICMA-RC VANTAGECARE RHS {STRATEGIC PLAN NO. 7, 6} / RECOMMENDED ACTION CLERK OF COUNCIL USE ONLY: APPROVED ❑ As Recommended ❑ As Amended ❑ Ordinance on 181 Reading ❑ Ordinance on 2nd Reading ❑ Implementing Resolution ❑ Set Public Hearing For CONTINUED TO FILE NUMBER 1. Receive and file rates for employee health insurance through CalPERS for calendar year 2018. 2. Receive and file rates for employee dental insurance with Delta Dental and MetLife, employee life and long term disability insurance coverage through Aetna and employee vision insurance through EyeMed for the calendar years 2018 and 2019. 3. Authorize the City Manager and Clerk of Council to execute the attached agreement with Reach, subject to non -substantive changes approved by the City Manager and City Attorney, to provide employee assistance plan services from January 1, 2018 to December 31, 2020 at a monthly cost of $1.85 per full time employee and $1.25 per part-time employee. 4. Authorize the City Manager and Clerk of the Council to execute an agreement with TASC, subject to non -substantive changes approved by the City Manager and City Attorney, to provide employee flexible spending accounts and Retiree Dental Billing services, effective April 1, 2017. 5. Receive and file continued agreement with ICMA-RC as the Plan Administrator of the VantageCare Retiree Health Savings Plan through December 31, 2018. DISCUSSION The City utilizes the services of two insurance brokers Keenan & Associates and Cook Insurance Services. Keenan is the broker of record on the life, accidental death & dismemberment (AD&D) 25E-1 Employee Group Insurance Renewals September 5, 2017 Page 2 coverage, long-term disability (LTD) insurance through the carrier Aetna, vision insurance through EyeMed, Flexible Spending accounts through TASC and EAP Program through REACH for all employees. Cook Insurance Service is the broker of record for dental coverage through the carriers Delta and MetLife. These coverages are sent out to bid by the brokers on a regular basis, usually in the summer of each year. Rates are finalized and issued in time for open enrollment in September of each year. The new rates are effective annually on January 1. The City purchases its medical insurance through CalPERS. The CalPERS health benefit program was established in 1962 under the Public Employees Medical and Hospital Care Act (PEMHCA). In 1967 the program was expanded to allow all public agencies access to the program. The City through a resolution amended its' contract with CaIPERS to allow it to participate in PEMCHA in 1996. CaIPERS is the second largest public purchaser of insurance in the nation behind the Federal Government and currently provides insurance for all State employees, public colleges and universities and to more than 1,000 school districts and local governments. To address the issue of rising health care costs, market stability, access and choice for contracting agencies, CalPERS utilizes a regional price approach grouping similar located agencies into regions. This approach and other polices are credited with holding down health care premiums, negotiating lower prices from hospitals and negotiating savings on prescription drugs. The change in CaIPERS basic HMO health plan rates range from a decrease of 10.60% for Blue Shield Access+ to an increase of 13.12% for Health Net Smart Care. The average increase for all HMO health plans will be 2.01% and the average decrease for all basic PPO health plans will be 2.46%. Currently the City contribution toward medical benefits for all bargaining units (except POA) is tied to the Kaiser rate (subject to labor negotiation agreements). Since Kaiser rates are increasing by 11.22% in 2018. Employees who chose plans other than Kaiser will be responsible for any increase in cost above the City contribution. Attached as Exhibit "A" are the CalPERS Health Premiums for 2018. Retirees are not included in the annual cost estimates. The Police Officers Association maintains its own insurance programs for medical, dental, vision and LTD coverage. The City purchases its dental insurance through Delta Dental and MetLife. Delta rates will not increase for 2018 and is guaranteed through December 31, 2019. MetLife rates will increase by 5% and is guaranteed through December 31, 2019. The City purchases its life and long term disability insurance through Aetna. The premium rates will not increase for 2018 and are guaranteed through December 31, 2020. The City purchases its vision insurance through EyeMed. The City does not contribute to the cost of this coverage. Employees are responsible for the full cost of this coverage. The premium rates will not increase for 2018 and will be guaranteed through December 31, 2020. 25E-2 Employee Group Insurance Renewals September 5, 2017 Page 3 City staff is asking for authorization to enter into an agreement with Reach Employee Assistance Inc., to provide employee assistance plan services for City employees for the term of January 1, 2018 to December 31, 2020. The City has previously contracted with Reach to provide these same services and has been pleased with the services provided. The Employee Assistance Program assists employees and their eligible dependents in handling problems that may be interfering with their performance on the job. Consultation for problems such as alcohol and drug abuse, legal, marital and family problems are available. REACH currently provides services under this program. Full time and part time employees are eligible to participate in the Employee Assistance Program. The costs to the City are billed on a monthly basis of $1.85 for full-time employees and $1.25 for part-time employees. The current rates will not increase for the term of the new agreement starting in 2018. Under the scope of the City's Insurance Benefit Broker Agreement with Keenan & Associates, is requesting to change its Flexible Spending Account and Retiree Dental Billing vendor from Conexis to TASC. City staff is requesting approval to enter into an Agreement with TASC to purchase employee flex spending accounts.. The City does not contribute to the employee's accounts; the employee pays for their contributions out of their paycheck. The City will be required to pay a nominal administration fee on behalf of the employees to administer the plan; a one-time set up fee of $300, administration fee of $4.25 per participant and an annual renewal fee of $100. The Agreement will automatically renew each year unless the City provides notice of cancellation pursuant to the terms of the Agreement. City staff is requesting approval to enter into an Agreement with TASC to administer the City's retiree dental billing. The City does not contribute to the premiums; the retirees pay the premiums directly to TASC. The City would be required to pay a nominal administration fee to administer the plan; a one-time set up fee of $250, administration fee of $2.25 per participant and an annual renewal fee of $125. The City has an established and ongoing agreement with ICMA-RC VantageCare Retirement Health Savings Plan to provide employees a benefit to deposit and withdraw tax free dollars for qualified medical expenses at retirement. FISCAL IMPACT Funds in the amount of $4,925,158 are budgeted and available in the Personnel Services Employee Benefits account (account no. 08109053-64010) to pay for City administered insurance coverage effective January 1, 2018. Funds in the amount of $9,500 are budgeted and available in the Section 125 Benefits account (account no. 08109052-64094) for flex spending administration. Funds in the amount of $8,898,207 are budgeted and available in the Employee Benefits account (account no. 08109053-64010) to pay for the insurance coverage administered 25E-3 Employee Group Insurance Renewals September 5, 2017 Page 4 by the POA. Funds in subsequent fiscal years will be budgeted and available depending on changes in the number of employees enrolled and benefit costs. FY 17-18* FY 18-19 FY 19-20** FY 20-21*** $ 4,934,658 $ 10,748,000 $ 10,383,977 $ 9,800,977 'Reflects Jan. — Jun. 2018 "Includes Dental Plan costs through Dec. 2019 'Includes vision and EAP costs through Dec. 2020 dwar Raya Executive Director Personnel Services Exhibits: A- CaIPERS 2018 Premiums B- Kennan Renewal Summary C- Delta Dental Premium Renewal D- MetLife Dental Premium Renewal E- Reach Agreement F -TASC Flex Agreement G -TASC Retiree Billing Agreement H- Vantage Care RHS Agreements D AS TO FUNDS AND ACCOUNTS: utierrez Executive Director Finance & Management Services Agency 25E-4 7111 nn17 'Dental and vision coverage Is an additional $38.00 per member per month premium. You will be billed directly for this amount. 2Dental benefit is an additional $15.05 per member per month premium. You will be billed directly for this amount. 'Dental and Vision coverage Is an additional $27.65 per member per month premium. You will be billed directly for this amount. EXHIBIT A 25E-5 CalPERS 2018 Monthly Premiums for Contracting Agencies Other Southern California Region Fresno, Imperial, Inyo, Kern, Kings, Madera, Orange, Riverside, San Diego, San Luis Obispo, Santa Barbara, Tulare Actives and Annuitants Effective Date: 1/1/2018 - 12131/2018 Basic;MontW Rate PLATY _ Employee Party '.1- ..Employee& Plan Cede Only Rata t Dependent Party Plan Code Rate EmPluyee8 2+ Dependents ° Parry, Plan Cotle Rate Anthem HMO select $659.69 478 1 1 1 $1,319.38478 2 2 $1,715.19 47831 3 Anthem HMO Traditional 735.08 407 1 1 1,470.16 072 40721 2 1,911.21 40731 3 BSC Access+ 695.97 142 1 1 1 1,391.94 1422 2 1,809.52 142 31 3 Health Net Salud y Mas 461.56 412 1 1 923.12 412 2 2 1,200.06 412 3 3 Health Net SmartCare 607.68 414 1 1 1,215.36 4142 2 1,579.97 4143 3 Kaiser Permanente 666.80 308 1 1 1,333.60 308 2 2 1,733.68 308 3 3 PERS Choice 698.96 323 1 1 1,397.92 3232 2 1,817.30 3233 3 PERS Select 654.74 082 1 1 1,309.48 .0822 2 1,702.32 0823 3 PERSCare 733.50 328 1 1 1,467.00 328 2 2 1,907.10 328 3 3 PORAC 734.00 207 1 1 1,540.00 2072 2 1,970.00 2073 3 Sharp UnitedHeaithcare 618.14 420 1 1 1,236.28 616.66 432 1 1 1 1,233.32 4202 432 2 2 2 1,607.16 1,603.32 4203 432 3 3 3 Supplement/Managed-Medicare" Monthly Rate (M) - - "- PLAN EmPI%ee, Only < Plan Gotle .Pony Empl%¢oa Rale 10ependent Plzn Calle Party Rate �Employeea 'Plan 2. Dependents Cotle Party Rate Anthem Traditional Med Adv Health Only $370.34 259 1 4 $740.68 2592 5 1 $1,111.02 2593 6 Anthem Traditional' Med Adv Healthmentauvision 370.34 109 1 4 740.68 109 2 5 1 1,111.02 1093 6 Kaiser Senior Adv 316.34 318 1 4 632.68 3182 5 949.02 3183 6 Kaiser Senior Advloental2 316.34 492 1 4 632.68 4922 5 949.02 4923 6 PERS Choice Med Supp 345.97 333 1 4 691.94 3332 5 1,037.91 3333 6 PERS Select Med Supp 345.97 0831 4 691.94 0832 5 1,037.91 0833 6 PERSCare Med Supp 382.30 338 1 4 764.60 5382 5 1,146.90 3383 6 PORAC Med Supp 487.00 208 T-4 970.00 2082 5 1,651.00 208 3 6 UnitedHeaithcare Grp Med Adv/PPO Health Only 330.76 386 1 4 661.52 3862 5 992.28 386 3 6 UnitedHeaithcare' Gr Med Adv PPO HWthlDentaliyision 330.76 387 1 4 661.52 3872 5 992.28 387 3 6 'Dental and vision coverage Is an additional $38.00 per member per month premium. You will be billed directly for this amount. 2Dental benefit is an additional $15.05 per member per month premium. You will be billed directly for this amount. 'Dental and Vision coverage Is an additional $27.65 per member per month premium. You will be billed directly for this amount. EXHIBIT A 25E-5 7/11/2017 'Dental and Vision coverage is an additional $38.00 per member per month premium. You will be billed directly for this amount. 'Dental benefit is an additional $15.05 per member per month premium. You will be billed directly for this amount. 'Dental and Vision coverage is an additional $27.65 per member per month premium. You will be billed directly for this amount. 25E-6 CalPERS 2018 Monthly Premiums for Contracting Agencies Los Angeles Area Region Los Angeles, San Bernardino, Ventura Actives and Annuitants Effective Date: 1/1/2018 -12/31/2018 `Basic_Mon thl 'Rate B':; PLAN Employee Plan Cod Farcy 'Employee& - Only 1Deendent 'Plan Code Dependent Party ,Employee& Party' Plan Code arty ,Rate Rate 2a Dependents Rate Anthem HMO Select $660.17 4131 1 $1,320.34 4132 2 $1,716.44 4133 3 Anthem HMO Traditional 784.72 402 1 1 1,569.44 402 2 2 2,040.27 402 3 3 BSC Access+ 613.29 144 1 1 1,226.58 14421 2 1,594.55 1443 3 Health Net Salud y Mas 404.32 443 1 1 808.64 4432 2 1,051.23 443 3 3 Health Net SmartCare 577.15 408 1 1 1,154.30 408 2 2 1,500.59 4083 3 Kaiser Permanente 642.70 306 1 1 1,285.40 306 2 2 1,671.02 306 3 3 PERS Choice 620.39 321 1 1 1,240.78 321 2 2 1,613.01 321 3 3 PERS Select 573.21 080 1 1 1,146.42 0802 2 1,490.35 080 3 3 PERScare 673.73 326 1 1 1,347.46 3262 2 1,751.70 326 3 3 PORAc 734.00 207 1 1 1,540.00 207 2 2 1,970.00 12073 3 UnitedHealthcare 602.78 14281 1 1 1 1,205.56 4282 2 1,56723 142831 3 Su pplenient/Managed Medicare Monthly Rate (M) ,PLAN Employee- - Only Plan Code Party Employee'& Rate IDependent Plan Code - Party Rate Employ", .Plan CodcParty l 2+pependents Rate Anthem Traditional Med Adv Health Only $370.34 2711 4 $740.68 271 2 5 $1,111.020 Anthem TradtUonal' Med Adv HealthlOentalNislan 370.34 166 1 4 740.68 166 2 5 1,111.02 Kaiser Senior Adv 316.34 316 1 4 632.68 3162 5 949.02 Kaiser Senior Adv/Dental' 316.34 493 1 4 632.68 4932 5 949.02 493 3 6 PERS Choice Med Supp 345.97 331 1 4 691.94 331 2 5 1,037.91 331 3 6 PERS Select Med Supp 345.97 081 1 4 I691.94 081 2 5 1,037.91 081 3 6 PERScare Med Supp 382.30 3361 4 764.60 3362 5 1,146.90 3363 6 PORAC Med Supp 487.00 208 1 4 970 .00 208 2 5 1,551.00 2083 6 UnitedHealthcare Grp Med AdvIPPO Health Only 330.76 382 1 4 661.52 382 2 5 992.28 3823 6 Grp hie Adv1P 0Hea Gr hied Ativ/PPO HeaIthlDentalMslon 330.76 383 1 4 661.52 383 2 5 99228 383 3 6 'Dental and Vision coverage is an additional $38.00 per member per month premium. 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Q N Q `' U f Q w v 01 Q Q Q U LL 00 V OlN <1 <01 Q M n v w 0 z .a `c W C Q d O � O Q� 01: 15t -y 25E-10 x%-avw.deltadent:)lin&cola June 23, 2017 CITY OF SANTA ANA 20 Civic Center Piz Santa Ana, CA 92701-4058 RE: Contract Renewal for CITY OF SANTA ANA Delta Dental PPO' Group# 00599 We appreciate your business and thank you for choosing Delta Dental of California. Your employees are among the millions nationwide who trust their smiles to Delta Dental. We are pleased to present you with your dental plan contract renewal information. We are committed to providing you with quality plan designs combined with excellent customer service. When reviewing your dental plan, we considered cost factors related to CITY OF SANTA ANA's dental service utilization and claims experience. Our analysis indicates that no increase in your current rate is necessary. We have calculated your rates based on the employer/employee contribution levels in your contract remaining the same. If the contribution levels and/or enrollment guidelines have changed or will change, please notify. us immediately, as such a change may affect your renewal rate. The following is the renewal information for your Delta Dental PPO' dental plan: Effective Date January 01, 2018 Contract Term�JniiCr7Cry> .,1, �O]8�-DecemherA,],-2019*'r % increase E000° Enrollee Only Current Rates $52.56 Enrollee + I or more Dependents $129.44 *PPO Premium Holiday: Renewal includes a one month premum holiday for January 2018. Delta Dental h)sumnce Canyrury. Iclephonc: 800.521-2651 Della Dental of Calilbmia 1'elephone: SNS -335-8227 EXHIBIT C 25E-11 Renewal Rates $52.56 $129.44 Della Dental Mid -Allan ie Region Delia Dccnml nl Deh n:ue, Inc. DcOa I)cmnl nl'thr District of Colwnhin Delta Dente oI*Nc, York. Inc. Delta Denud of I'auls)'I :mia (\Inrrl:null Delta Dental ol'Wem Virginia telephone. %0()-932-07x3 O 25E-12 MetLife" July 20, 2017 Re: City of Santa Ana Renewal —1/1/2018 Dear Benefits Coordinator, MetLife appreciates the opportunity to be a part of your benefit program. This letter confirms your renewal for the 2018 plan year. These rates will be good from 1,1`=20118.=12'31-=20 9. In determining the rates for the coming plan year, we have evaluated your plan experience, taking into account the credibility of the experience and the demographics of your group. Our objective in the renewal process is to identify rates that will maintain the overall financial stability of your benefit program. We have set the following rates for the coming year: Coverage DHMO • Em to ee Current Renewal Change in RatefFee Rate/Fee Rate/Fee only $27.70 $28.53 �t3:OJ3 • Em to ee + Famil $47.34 $48.76 (�:EUQN The rates shown above assume your existing plan design, contribution structure and group demographics remain the same. Please do not hesitate to contact me at 949-202-9020 if I may answer any questions or assist in any way. Once again, thank you for the privilege you have extended to us. You are the reason we are in business. We look forward to continuing our relationship in the months and years ahead. Sincerely, Bailie Schira Account Executive Dental HMO plans in California, Florida and Texas are available through a domestic company in the applicable state named SafeGuard Health Plans, Inc. The SafeGuard companies are part of the MetLife family of companies. Request to Notify Alaska Residents of Impending Coverage and/ar Premium Changes Undei Alaska Statute 21.36.2)5, covered individuals residing in Alaska must he notified of impending coverage and)or premium changes, as appl,rable if you Dave employees residing in Alaska who aie invered under Met[-Ke's Disahillty, Dental, Vision of Accidental D dth and Disnembennent pohues, eve ask that you provitle them with arruten notice at least 45 days in advance of dhe effective elate or the renewal, nofifyina Main that coverage andior prenhiums may change. Once renewal details are finalized, a second notice must be provided setting forth the details of the coveraue nr pfenimin change_ If you would like wordrng for mese notices, please contact your Mettle service team 25E%BIT 25E-14 REACH EMPLOYEE ASSISTANCE PROGRAM SERVICES AGREEMENT This Employee Assistance Program Services Agreement is made and entered into as of_ day of August, 2017, between REACH Employee Assistance, Inc. (hereinafter referred to as "REACH"), a California corporation, and the City of Santa Ana, a charter city and Municipal Corporation organized and existing under the Constitution and laws of the State of California (hereafter referred to as "City".) Whereas REACH is engaged in the Employee Assistance Program Services business and desires to service City; and Whereas City desires to obtain the Employee Assistance Program Services of REACH. It is therefore agreed as follows: This is a contract for service outlining the duties and responsibilities of REACH Employee Assistance, Inc., to the City of Santa Ana. I. Below are listed the Scope of Services provided by the REACH: I: Assessnrent/CounselingfReferral for Employees and Dependents. A total assessment will be administered for a well-rounded analysis of the client's problem. Employees and immediate family members are entitled to up to three (3) sessions per incident every six (6) months. REACH provides professional assessment/counseling to the point of referring the client to an outside counseling professional or agency. In addition, REACH provides follow-up consultation. The number of sessions offered, within this limit, will be at the sole discretion of the REACH counseling staff. The City will be assigned a REACH liaison person. REACH provides quality, experienced counselors knowledgeable in assessment skills to provide personal counseling to employees and immediate family members. REACH also provides qualified and experienced staff to assist management on all aspects of Employee Assistance Program. Dr Marcus Dayhoff is administratively, operationally and clinically responsible for REACH. A. Confidentialitv and Release of information As a general rule REACH shall not disclose to the City the identity of City employees or immediate family members of City employees who elect to participate in the REACH Program offered under this Agreement. Exceptions Notwithstanding the above, REACH shall release to the City in writing the following information on employees who have been referred into the REACH Program as a condition of employment with the City: A) Whether employee has agreed to participate in the Assistance Program. EXHIBIT E 25E-15 B) List of all appointments of employee kept and missed, together with reason, if any, for missing the appointment. C) Submission of the employee's anticipated treatment plan as a participant in the Program. This plan shall consist of the following: 1) The anticipated number of visits, appointments, or sessions requested of the employee. 2) The type of therapeutic procedures in general terms that the employee is to receive during the employee's participation with the REACH Program or the treatment provider(s). 3) Description of the treatment service provider the employee is referred to by REACH. 4) Any other information not contained in the employee's treatment service provider medical record deemed appropriate by the City to evaluate the employee's participation in the Assistance Program. D) Any conclusion or opinion of REACH or employee's treatment service provider that the employee is limited or restricted in his/her ability to perform the employee's job duties, such limitation may be, but not necessary, limited to physical, psychological, or medical reasons. E) Any conclusion or opinion of REACH or employee's treatment service provider that employee's participation may necessitate employee's absence from the City. F) That employee has failed, refused, or otherwise has discontinued to proceed with the REACH Program or any treatment service provider. G) Report consisting of the following: 1) Diagnosis 2) Summary of treatment or therapeutic procedures 3) Disabilities, limitations, or restrictions of employee 4) Recommendation on further treatment. The above information shall be considered confidential information not subject to disclosure by REACH unless the City employee has on file with REACH and any treatment service provider in the REACH Program an irrevocable authorization(s), RELEASE OF INFORMATION to the City. On receipt of the City's request for the above information, REACH shall notify in writing, the City employee of the City's request. NOTE: The City agrees that in cases where an employee agrees to be referred by management to REACH, the Supervisor will seek written permission from the employee to inform REACH of the circumstances leading up to the referral. z 25E-16 The City agrees to in no way insist or demand confidential information from the REACH program on specific individuals who do not want their information released to the City. Service Providers: Exceptions will also be made in cases when the employee and/or immediate family members sign a written release authorizing the release of information by REACH to one or more agreed upon seivice providers. 2. Definitions a. "Client" shall mean an employee or his/her immediate family member participating in the REACH EAP program. b. "Treatment Service Providers" or "Service Providers" shall mean an outside counseling professional or agency, referred by REACH, whose services will be paid by the client. 3. Counseling Hours REACH provides counseling hours from 8:00 a.m. to 8:00 p.m. Monday through Thursday, Friday 8:00 to 5:00 p.m. and will respond appropriately and effectively to employee needs. Every attempt will be made to see management referrals and employees in crisis as early as possible to the time of call and no later than 24 hours (during business hours) of the call being made. All other clients will be seen within 48 hours of the call being made. The City agrees to provide REACH with names and telephone numbers of liaison individual(s) at the City who can be contacted in cases of emergencies and keep REACH appraised of changes in contacts and telephone numbers. 4. 24 -Hour Availability, 7 days a week REACH provides confidential intake and psycho -social assessment and counseling to the point of referral to employees and their immediate family members with a 24 hour telephone service. REACH assures that no calls go unanswered and that all crisis callers receive courteous and prompt service. During non -business hours, all calls answered by the REACH answering service will be connected to the on-call counselor. The REACHline number is 1-800-273-5273. 5. Location Employees and family members will have a choice of counseling either at one of our several conveniently located offices or at one of our service provider's office. 3 25E-17 6. Referral Network When necessary, REACH will refer employees and dependents to appropriate, cost effective, geographically convenient and high quality services provided by individuals and agencies which have been screened by our staff. 7. Monitoring/Follow-up REACH will monitor and follow-up as long as appropriate all people referred by the REACH program to outside individuals and community resources to assure the problem is resolved and that the person is satisfied with the quality of referrals. In cases of management referrals, REACH will also follow-up regularly with the City on status of job performance. 8. Service Utilization Reports REACH will provide quarterly confidential reports on service utilization, aggregate client profiles, assessed problems and outcome at case closure. Customer satisfaction reports will be available upon request by the City. 9. Benefits The City agrees to provide REACH with copies of all the City employee benefit plans and appraise REACH of all changes as they occur. 10. Avoiding Conflict of Interest REACH agrees to avoid conflict of interest by providing up to three (3) referrals to clients based on competency, geography and the most cost effective modality to deal with the client's problem(s). No referrals will be made to the private practices of REACH counseling staff members or to any private practitioner and/or agency with whom a REACH counselor has an economic relationship. Only the City can make exceptions to this rule. 11. Alcoholism and Chemical Dependency Intervention Services REACH provides job related alcoholism and chemical dependency intervention services as required. 12. Poliev and Procedure The City agrees to consider implementing a policy and procedure statement on employee assistance when appropriate. REACH will provide technical assistance to the City staff in writing a policy and procedure statement on employee assistance. 4 25E-18 13. Training REACH will provide Management and Supervisory training sessions annually. It is recormnended that no more than 25 managers/supervisors attend each session. The purpose of these training sessions is to make managers and supervisors aware of City employee assistance program policy and procedures, of how to identify poor job performance as it relates to personal problems and to familiarize them with the processes of referrals and follow-up..The effectiveness of each training session will be evaluated. 14. Management Guidelines REACH supplies on request Management and Supervisor Employee Assistance Program guidelines for inclusion in City personnel management guidelines. 15. Manager/Supervisor Consultation and Assistance REACH will assist managers and supervisors calling REACHIine for consultation on how to deal with specific employee incidents or problems, which may require EAP intervention. The City agrees to encourage managers and supervisors to take advantage of this consultation service. 16. Program Promotion The City agrees to support REACH in developing a yearly EAP program promotion plan. a. EAP orientation classes for employees in groups of up to 50 will be available to the City as a means of introducing City EAP policy and procedures and utilization of REACH services. b. "Munch & Learn" presentations will be conducted periodically upon request by the City, at City locations to maximize utilization of REACH services. C. REACH brochure & REACHIine cards will be supplied to the City for distribution to all employees. d. REACH Frontline will be electronically supplied to the City quarterly for distribution to all supervisors. e. REACHIine.conr will be available for online use to all employees and family members. Employees will be supplied a password as mentioned on REACH employee brochure for online secure area access. f. RE, ACHIine Posters will be supplied from time to time to the City for posting on official staff bulletin boards. 5 25E-19 g. Originals of promotional materials for inclusion as short articles in internal staff newsletter or as check stuffers will be supplied upon request by the City. h. REACH staff will participate at the City's employee benefit fair upon request. i. REACH will assist with drafting of any EAP related materials to announce REACH services to employees. 17. Quali REACH conducts on-going quality assurance audits on all aspects of the program from inception to end of the contract year. REACH will supply the City with quarterly reports. II. THE CITY OF SANTA ANA REALIZES AND UNDERSTANDS 1. Top management support and commitment is essential to the success of the REACH Employee Assistance Program at the City of Santa Ana. 2. REACH is a totally confidential program. The City will only be aware of employees referred officially by management and information about that employee will not be released without written consent of the employee. 3. REACH will not, in all cases, be able to resolve the employee's or dependent's problem(s) in the set number of counseling sessions. In such cases the employee or family member will be referred to quality, cost effective resources available within the community. 4. Employees and dependents will not be charged for the services provided by REACH. If referrals are necessary, those referrals may result in additional cost to the City's benefit plan and may result in added costs to the employee or family member. 5. The REACH program is made available to all fiill- and part-time employees and their dependents. The REACH benefit starts on the first day of employment. 6. It is anticipated that the yearly employee utilization rate will be a minimum of 6-8%. The REACH promotional program will aim at achieving at least this utilization rate. III. TERMS AND CONDITIONS The Agreement period will be from January 1, 2018 to December 31, 2020. 2. The total cost to the City for the services to be provided to the City and its employees by REACH under this Agreement shall be $1.85 per fill time ennployce per month, and $1.25 per part time employee per month. While the number of persons employed by the 6 25E-20 City may fluctuate from time to time during the term of this Agreement, the City agrees the amount of compensation payable to REACH during the term of the Agreement shall be based on the number of persons employed by the City at the beginning of the month invoiced for. The beginning employee count will be 970 full time and 490 part time. The City will be invoiced on the first of each month for that month's installment. Checks will be made payable to REACH Employee Assistance, Inc. and mailed to 650 N. Rose Drive, #350, Placentia, CA 92870 - Attn.: Accounts Receivable. 4. The City will make payment within 30 days from the date of the receipt of the invoice from REACH Employee Assistance, Inc. 5. REACH Employee Assistance; Inc. agrees to indemnify, defend, and hold harmless the City, its officers, employees, agents and representatives, from any and all claims, demands, purported liability, or consequential damages of any kind or nature arising out of or in connection with REACH's acts or omissions in carrying out the terms of this Agreement or exercising the rights herein granted; excepting those claims, demands, purported liability, or consequential damages which arise out of the sole negligence of City. 6. REACH agrees to maintain during the course of this Agreement the following insurance coverage: a) Comprehensive general liability insurance coverage, including personal injury and contractual liability coverage, in an amount equal to One Million Dollars ($1,000,000.00) per occurrence, combined single limit; b) Worker's Compensation insurance as required by State of California statutes; C) Professional liability insurance with a One Million Dollar ($1,000,000.00) limit, per occurrence. REACH agrees to keep such policy in force and effect for at least five (5) years from the date of completion of this Agreement. Also, the City of Santa Ana, its officers, agents and employees will be named as additional insured on the above referred comprehensive general liability coverage and REACH will provide an endorsement to that effect. Such insurance shall (a) name the City, its officers, employees, agents, volunteers and representatives as additional insured(s); (b) be primary and not contributory with respect to insurance or self-insurance programs maintained by the City; and (c) contain standard separation of insured's provisions. Such insurance will be evidenced by certificate and issued by companies licensed to do business in California and acceptable to the City. Before REACH perforins any work, it will furnish certificates of insurance and endorsements, as required by City, evidencing the aforementioned general liability, and professional liability insurance coverages on forms acceptable to the City 25E-21 which shall provide that the insurance in force not be canceled or modified without 30 days prior written notice to the City. In the absence of satisfactory insurance coverage, City may, at its option: (a) procure insurance with collection rights for premiums, attorney's fees and costs against REACH by way of set-off or recoupment from the sums due REACH, at City's option; (b) immediately terminate this Agreement; or (c) self insure the risk, with all damages and costs incurred, by judgment, settlement or otherwise, including attorney's fees and costs, being collectible from REACH, by way of set-off or recoupment from any sums due REACH. 7. NO ASSIGNMENT. REACH shall not assign or transfer this Agreement or any rights hereunder without the prior written consent of the City and approval by the City's City Attorney, which may be withheld in the City's sole discretion. Any unauthorized assigned or transfer shall be null and void and shall constitute a material breach by REACH of its obligations under this Agreement. No assigmnent shall release the original parties or otherwise constitute a notation. S COMPLIANCE WITH LAWS. REACH shall comply with all Federal, State, County and City laws, ordinances, rules and regulations, which are, as amended from time to time, incorporated herein and applicable to the performance hereof. 9. ATTORNEY FEES. If any action at law or in equity is brought to enforce or interpret the terns of this Agreement, the prevailing party shall be entitled to reasonable attorney's fees, costs and necessary disbursements in addition to the relief to which such party may be entitled. 10. INTERPRETATION. (a) Applicable Law. This Agreement, and the rights and duties of the parties hereunder (both procedural and substantive), shall be governed by and construed according to the laws of the State of California, with venue in Orange County. (b) Entire Agreement. This Agreement, including any exhibits attached hereto, constitutes the entire agreement and understanding between the parties regarding its subject matter and supersedes all prior or contemporaneous negotiations, representations, understandings, correspondence, documentation and agreements (written or oral). To the extent there is any conflict or inconsistency between the terms and provisions of this Agreement and the exhibits attached hereto, the terms and provisions of this Agreement shall govern the rights and obligations the parties hereto. (c) Written Amendment. This Agreement may only be changed by written amendment signed by REACH and the City Manager of the City or other authorized representative of the City, subject to any requisite authorization by the City Council. Any oral representations or modifications concerning this Agreement shall be of no force or effect. 25E-22 (d) Severability. If any provisions of this Agreement is held by any court of competent jurisdiction to be invalid, illegal, void, or unenforceable, such portion shall be deemed severed from this Agreement, and the remaining provisions shall nevertheless continue in full force and effect as fully as though such invalid, illegal, or unenforceable portion had never been part of this Agreement. (e) Order of Precedence. In case of conflict between the tenns of this Agreement and the terms contained in any document attached as au exhibit or otherwise incorporated by reference, the terns of this Agreement shall strictly prevail. (f) Choice of Forum. The parties hereby agree that this Agreement is to be executed in accordance with the applicable laws of the State of California, is entered into and is to be performed in the City of Santa Ana and that all claims or controversies arising out of or related to performance under this Agreement shall be submitted to and resolved in a forum within the City of Santa Ana at a place to be determined by the rules of the forum. 11. TIME OF ESSENCE. Time is strictly of the essence of this Agreement and each and every covenant, term and provision hereof. 12. AUTHORITY OF REACH. REACH hereby represents and warrants to the City that REACH has the right, power, legal capacity and authority to enter into and perform its obligations under this Agreement, and its execution of this Agreement has been duly authorized. 13. NOTICES. Any notice or demand to be given by one party to the other shall be given in writing and by personal delivery or prepaid first-class, registered or certified mail, addressed as follows. Notice simply to the City of Santa Ana or any other City department is not adequate notice. To City: Clerk of the City Council City of Santa Ana 20 Civic Center Plaza (M-30) P.O. Box 1988 Santa Ana, CA 92702-1988 Fax 714- 647-6956 Copies to: Executive Director of the Personnel Services Agency City of Santa Ana 20 Civic Center Plaza (M-24) P.O. Box 1988 Santa Ana, California 92702 Fax 714-647-6930 City Attorney 25E-23 City of Santa Ana 20 Civic Center Plaza (M-29) P.O. Box 1988 Santa Ana, California 92702 Fax 714- 647-6515 If to REACH: REACH Employee Assistance, Inc. 101 East Lincoln Avenue, Suite 230 Anaheim, CA 92805 Attn.: Dr. Marcus Dayhoff Fax: 714-533-5700 Any such notice shall be deemed to have been given upon delivery, if personally delivered, or, if mailed, upon receipt or upon expiration of three (3) business days from the date of posting, whichever is earlier. Either party may change the address at which it desires to receive notice upon giving written notice of such request to the other party. 14. TERMINATION FOR CONVENIENCE (Without Cause). The City or REACH may terminate this Agreement in whole or in pail at any time, for any cause or without cause, upon sixty (60) calendar days' written notice to the other. If the Agreement is thus terminated by the City for reasons other than REACH's failure to perform its obligations, the City shall pay REACH a prorated amount based on the services satisfactorily completed and accepted prior to the effective date of termination. Such payment shall be REACH's exclusive remedy for termination without cause. 15. DEFAULT. In the event either party materially defaults in its obligations hereunder, the other party may declare a default and terminate this Agreement by written notice to the defaulting party. The notice shall specify the basis for the effective date of termination stated in such notice, which date shall be no sooner than ten (10) days after the date of the notice. Termination for cause shall relieve the terminating party of further liability or responsibility under this Agreement, including the payment of money, except for payment of services satisfactorily and timely performed prior to the service of the notice of termination, and except for reimbursement of (1) any payments made by the City for service not subsequently performed in a timely and satisfactory manner, and (2) costs incurred by the City in obtaining substitute perfornance. 16. EQUAL EMPLOYMENT OPPORTUNITY. During the performance of this Agreement, REACH agrees as follows: a. REACH shall not discriminate against any employee or applicant for employment because of race, color, religion, sex, national origin or mental or physical disability. REACH will ensure that applicants are employed and that employees are treated during employment, without regard to race, color, religion, sex, national origin or mental or 10 25E-24 physical disability. Such actions shall include, but not limited to the following: employment, upgrading, demotion or transfer, recruitment or recruitment advertising, layoff or termination, rates of pay or other fors of compensation and selection training, including apprenticeship. REACH agrees to post in conspicuous places, available to all employees and applicants for employment, a notice setting forth provisions of this non- discrimination clause. b. REACH shall, in all solicitations and advertisements for employees placed by, or on behalf of REACH, state that all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, or mental or physical disability. c. REACH shall cause the foregoing paragraphs (a) and (b) to be inserted in all subcontracts for any work covered by this Agreement, provided that the foregoing provisions shall not apply to subcontracts for standard commercial supplies or raw materials. 19. CONFLICT. REACH hereby represents, warrants and certifies that no member, officer or employee of REACH is a director, officer or employee of the City, or a member of any of its boards, commissions or committees, except to the extent permitted by law. (Signatures on Following Page) 25E-25 IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: Maria D. Huizar Clerk of the Council APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By: &Uy ' N Laura Rossini Senior Assistant City Attorney RECOMMENDED FOR APPROVAL: Edward Raya, Executive Director Personnel Services Agency CITY OF SANTA ANA Cynthia J. Kurtz Interim City Manager REACH Employee Assistance, Inc. By:"Director MarcCEO 12 25E-26 SECTION I , THIS SERVICE LEVEL AGREEMENT ("Agreement"), is entered into b; Total Administrative Services Corporation ("TASC") and the Employer identified Services Plan Application ("Plan Application') as the Plan Sponsor, City of Sa. Agreement is effective on the date of the Plan Sponsor's signature on the Plan App] is attached as Exhibit A to.this'Agreement The terms of.this Agreetnent.apply to tl services identified on the Plan Application.' The Plan Sponsor is duly organized, and fully authorized to enter into this Agreement. The individual executing the on behalf of the Plan Sponsor is fully authorized to do so. 1. Scope of Relationship A. As used; in this Agreement, the terms Administrator (commonly referred Administrator), Plan Sponsor, Named Fiduciary and Plan Assets meaning given to such. terms by the Employee Retirement Income S l97 } (ERISA), as amended. TASC is not the Plan Administrator, the or a Named Fiduciary for any Plan Identified on the Plan Applicatior not accept a fiduciary role or status for any Plan: TASC is and u Independent contractor with respect to all services provided. TASC Sponsor are not partners or engaged in ajoint venture. TASC does not i employee contributions or plan assets. B. All fees paid toTASC by the Plan Sponsor, regardless of the payment are paid from the general assets of the Plan Sponsor. C. TASC is not a lain firm and is not providing legal or tax advice. All EXHIBIT F 25E-27 Group t. This which s) and 'he Plan ave the Act of ponsor, C does :rain an to Plan or hold verbal communication provided under'the terms of this Agreement are general n naIure and not intended to constitute legal or tax advice. The products and servi es rovided pursuant to this Agreement may ,have legal and tax consequences. A y q estions regarding Plan Sponsor's particular needs, requirementts, circumstanc , of the tax consequence of any product or service offered under this Agreement mu f be Jirected to Plan Sponsor's own advisor(s) at the Plan Sponsor's expense. 2. Services Provided bvTASC .A. TASC shall use ordinary care and due diligence in the performanct of i s duties under this Agreement and provide timely administration and manai erne it of the Plans) Identified in the Plan Application as outlined in the applil able product administration manual and/or materials incorporated by express ret ren' a to this Agreement Services provided by TASC are subject to change upon Vritt n notice to the Plan Sponsor or as required by law. B. In the case of Flex System, and TASC HRA Plans, TASC will also rov de audit assistance support under the terms of the applicable Audit Guarante -T SC may change any feature, function, brand,'third party provider, or attribute of a Service, or any element of its systems or processes, from time to time, provded (hat such changes do not have a material adverse Impact on the performance or cast of the Service. 3. Responsibility of the Plan Sponsor A. The Plan Sponsor has final and complete discretion over the PIns. The Plan Sponsor Is the Plan Administrator under ERISA The Plan Sponsor •hall) have the sole and Final discretionary authority in respect to all legal and 25E-28 functions of the Plan. The Plan Sponsor acknowledges and iccepts sole responsibility for the payment of all Card Transactions. TASC can Mist he Plan Sponsor in the recovery of Card Transaction amounts reported t s fir; udulent transaction activity by Participants, provided however that Plan Pa icipants comply with the terms outlined in the cardholder agreement f r the timely reporting of such fraudulent activity and the Plan Sponsor complies with policies and procedures for reporting such.fraudulent transaction activity, B. The Plan Sponsor must present to TASC, in an accurate, comple a anti timely manner, all relevant and requested information necessary or des red for administrative functions to be performed by TASC in a standard TASC "ormat.or an alternative format agreed upon by the parties. TASC shall rely o the accuracy and timeliness of Information provided to it by the Plan Sponsor. rAS has no responsibility to review or verify data provided by the Plus Sponsor TAC is not responsible for detecting illegal .acts by, and/or misrepresentation of, the Plan. Sponsor's employees or*representatives. TASC shall have no re poh bility or liability for failure to provide any service for which the Plan S ons! has not provided complete data to TASC in an agreed upon format. C. Failure to meet deliverable expectations, including but not limited to thpse noted above and elsewhere in this Agreement, in an accurate, comp/ to a timely manner will result in a status of delinquency. Delinquency statu will result in i service interruptions anWor delays. TASC wilt have no liability for any losses due to the failure to perform during the time the Plan Sponsor is in deli que�,cy status. 3 25E-29 D. It is the Plan Sponsor's responsibility to educate and inform Plan participants on the services being provided, including the delivery of (where needed) as well as compliance documents (e.g., Surtrimajy Plan Description). The Plan Sponsor is responsible For executing and etai ling the Bdsiness:Associate Agreement (where applicable) provided in thea ministration materials. 4. Financial Responsibilitv of.the Plan Sponsor A. Respoiis bility'for payment of all Plan benefits lies with the Plan Spo isoJAII Plan benefits are paid from the general assets of the Plan Sponsor. Unless in al emotive method,oEpayment is mutually agreed upon by the parties, TASC Fee 'will be collected from the Plan Sponsor via ACH.transaction and the Plan S ons r hereby authorizes TASC to initiate credit/debit entries: to the bank accouLIC n icated in the Plan Application and further authorizes the Plan Sponsor s bao debit the same to such account. If for any reason, TASC does not receive pet for any TASC fees defined on the Application within ten (IO) busines da s of the I Expected Date of Receipt TASC may place all Plan processing or holt until all past due TASC fees are paid. TASC reserves the right to charge a eas liable fee for all debit entries that reject for insufficient funds or closed ccot nts. This authority will remain in full force until TASC has received from the Plan Sponsor of its termination of this authority in such tine apd in such manner as to afford TASC and the Plan Sponsor's bank a reasona le opportunity I to act on it. It is understood that the purpose of this authorization is tol provide a means of payment for the administrative services provided to the Ppan Sponsor by 25E-30 i TASC. Regardless of the fee payment options identified on the Appli attoor any circumstances where the Plan Sponsor uses a third party to pay Plat ben Fits. all Plan contributions and liabilities are the responsibility of the Plan S nso�. B. TASC reserves the right to correct any processing errors, making a re• soname effort to recover any payment made in error for any reason and the elan Sponsor authorizes TASC to debit or credit the Plan Sponsor's account as necessary to correct such errors. TASC will invoice or make adjustments to the Ian orto the i Plan. Sponsor as deemed necessary. TASC will interpret state uncla rid roperty I laws iA a reasonable manner to divest itself from Funds attril utedto Plan participlutt reimbursement checks not presented. for payment. C. The Plan Sponsor understands and agrees Plan Sponsor shall be liab a togand hold TASC harmless from any and all, fees or penalties assessed by the Int malllRevenue I Service, the Department of labor or any other federal, state an 'or local, government agency arising from the Plan; except in the case where is s own that a loss is a direct result of a negligent act or omission on the part f TiSC. Any request for refund's or adjustments by Pian Sponsor will be prose sed my after verification is made that sufficient funds were received by TASC "0 the Plan Sponsor's bank account to coverall payments made by, and fees and o[he amounts i due to, TASC. No refunds or adjustments will be made while the I Ian Iponsor is in default under this Agreement. $. Terms of Pavment A. The Plan Sponsor agrees to pay TASC for services provided under his tlgreement in accordance with the fees determined on the Plan Application Plymment for 5 25E-31 6. services will occur via E -pay or invoices will generate prior to t e ap licable service period and are due according to the terms on the Invoice. rad ition to the fees determined on the Plan Application, all interest on Plan 7ces hall be retained by TASC as a supplemental fee and such fees shall be cons dere�I earned at such time as any Interest accrues. Q. Any Plan funding ACH debits that are rejected or which, for any r aso, , are not processed through the Plan Sponsor's bank will result in the Plan b ing laced in delinquency status until such ACH debit is properly processed or therwise resolved. C. TASC may adjust administrative fees on an annual basis at renev at w ith thirty (30) days written notice of the fee change. Default A. Either party shall :pe in default under this .Agreement upon the occ trreitCe of one or more of the following events: (i) the failure of that party to perfor n an material term, condition or covenant of this Agreement; (ii) the ceasing of he cl nduct of i active business by the party; (iii) the institution of proceedings on er b nkruptey ! i or hisolvency laws by, for or against the party, or the appointment f tl receiver for that party or for that party's assets or properties, (iv) an assn Time!it by that party for die benefit of creditors, (v) and an admission by that paro s inability to pay its debts as they become due, or (vi) non-compliance with taw Illlaoverning I' the transactions under this Agreement. B. Upon Default by either party that is non-compliant with applicablt lase governing the transactions under this Agreement. when the non-compliance c uld feasonably 11 25E-32 result in an excise tax, penalty, or claims liability, all obligation. of the non - defaulting party shall.cease. No term of this Agreement can be read to e, tend the term of this Agreement beyond the day that a Pary discove s such non- compliance. At the non -defaulting party's discretion, this Agreemeni can be continued upon satisfaction that the non-compliance has been rec ifiec and the effected persons made financially whole bythe non-compliant defa dting Party. C. TASC shall have no additional duties under this Agreement ref ed to a Plan Sponsor who institutes proceeditigs under Chapter 7 of the Bankntcyll,Code, or makes An appointment of a trustee or receiver for the disposition of thein assets or properties, or an assignment of assets for the benefit of creditors, o an�dmission of its inability toy pay Its debts as they become due. TASC wi H c+tinue to administer services for such a Plan Sponsor through the earlier oftlu dat4n which the Plan Sponsors;Tlans terminate entirely, the date the Plan Spon r is no longer able to continue their business, or the last period that TASC hid for its services. D. For all other incidents of default, the non -defaulting party may, ad itsption and by written notice to the other party, terminate this Agreement if the lefallt remains uncured for thirty (30) days after the non -defaulting patty provide wriIten notice to the defaulting patty of such default. If such default remai i un ured, the tennination is effective as explained below. Any terminations all e without prejudice to any other rights and remedies, which the non-defau tinglparty may have against the defaulting party with respect to such default TA C's Tbligations i are subject to the Plan Sponsors timely performance of its bli¢ations and 7 25E-33 I responsibilities under this Agreement including but not Iimited to pr( vididg, TASC with correct, complete and timely data or other information, or no ices equired under this Agreement; and to timely pay fees; E. TASC will not be responsible for any damages or losses due to a i efau.t by the Plan Sponsor. [n the event of a default by the Plan Sponsor: L) This Agreement may be terminated and all amounts due and to econ a due to TASC shall become hnmediatelydue and payable, at TASC's so' opt on; and, 2) 'TASC reserves the right to suspend all or any services to the Plat Sp nsor and the Plan, including the reporting or processing of Plan data and I aym nts, and 3) TASC will not be responsible for the timeliness or accuracy of ny r porting, participant payments, tax deposits or payroll, payments until the efault(s) has been cured and: all outstanding obligations the Plan Sponsor hav befit. paid to TASC. 7. Termination and Renewal of Agreement A. This Agreement will renew automatically. Either party may can nate this A,�reement with sixty (60) days written notice. If setvices are to ina�ed ander this Agreement, the Plan Sponsor will be responsible for rowing any outstanding services required under the Plan. I B. Yotwitlistanding the term described above, ACA Employerepoiting will continue for a l2 -month initial term, thereafter renewing autom• tically for one year terms. Either party may terminate this Agreement with 'ixtyl(60) day written notice. III C. [f services are terminated tinder this Agreement fix reasons oth r tha+ a TASC I i 3 I 25E-34 uncured default or TASC material non-performance, the Plan SI onsdr will be responsible for providing any outstanding services required and the Ian and payment of the ACA Reporting fees until the end of the calendar. 'ear II� � which the termination occurred. In case of terminations. there are no j efunls of the set-up fee, and no refunds of any tees applied to the service to the �atendar i year in which the services are terminated. D. Either party may terminatethisAgreement due to. a default' y giving the defaulting party ten (10) day written notice of the termination IF he hon- defaulting party allowed a thirty (30) day cure period the ten (l ) da written notice will be at the end of the cure period. E. Upon and after the expiration or termination of this Agreem t, tite rights I granted to the Plan Sponsor pursuant to this Agreement shall i eve back to TASC. TASC may provide the Plan Sponsor with sample form;, pr< cedures, scripts, marketing materials or other similar information (collectively, "Materials"). Plan Sponsor shall have a license to use ivlaterials if ally, solely in connection with its use of the Services, Software, or Detivera' les d�uing the term of this Agreement and solely in a manner that is wnsi tent with the Agreement. Plan Sponsor's license to use the Materials shall expire immediately upon termination of the Agreement. Plan Sponsor is responsible for its use of _Materials and bears sole liability for any such ise. Fhe Plan Sponsor shall refrain from any further direct or indirect use of c r relrence to TASC marks, systems, publications, manuals, brochures, d cmmlents and computer databases in connection with the marketing, use, in,pleni,enration, 9 25E-35 license, sale or distribution of any program, system or Plan ori' F. Finally, the termination of this Agreement shall not affect the c Sponsor not to infringe on TASC's trademarks and copyrig disclose and keep confidential all said confidential information Plan Sponsor by TASC. 8. Confidentidlity If TASC receives from the City information which due to the nature of such reasonably understood to be confidential and/or proprietary, TASC agrees that or disclose such information except in the performance of this Ab eetnent, and ft exercise the same degree ofcare 'it uses to protect its own information of lice imp no event less than reasonable Gare. "Confidential Information" shall include information. Confidential information includes not only written informat infonniition transFarred orally, visually, electronically, or.by other means. information disclosed to either party by any subsidiary and/or agent of the other p: by this Agreement. The foregoing obligations of oon-use and nondisclosuresha any information that (a) has been disclosed in publicly available sources; (b) is, th of the TASC disclosed in a publicly available source; (c) is in rightful possessior without an obligation of confidentiality, (d) is required to be disclosed by operat (e) is independently developed by the TASC without reference to information di City. 9. Insurance TASC shall provide plan Sponsor a certificate of insurance demonstratin liability insurance coverage with a combined single limit of not less than S 1,0001, 10 25E-36 TASC: Plan not to to the nation is I not use i, ees to :e, but in mpublic nit also fidential covered apply to no fault eTASC 'law; or 1 by the claim with 52,000,000 in the aggregate prior to the start of work pursuant to this Al following requirements apply to the insurance to be provided by TASC pursuant A. TASC shall maintain all insurance required above in full force and effec period covered by this Agreement. B. Certificates of insurance shall be furnished to the City upon execution and shall be approved by the City. C. Certificates and policies shall state that the policies shall not be cant I coveragor changed in any other material aspect without thirty (30) notice to the City. to. Indemnification A. TASC shall indemnify the Plan Sponsor, its directors and of harmless from and against any and all actions, claims, lawsuit judgments, costs, taxes or similar assessments, penalties and exper reasonable attorney's fees, resulting from a direct result of TASC's willful misconduct. B. The Plan Sponsor shall indemnify and hold TASC, its directors,offr( agents and assigns harmless from and against any and all actions, c settlements, judgments, costs (including but not limited to, cos premiums paid with respect to the Plan), taxes or similar assessmen expenses, including reasonable attorney's fees, or other obligations arising out of or in any way connected with the Plan, inclu administration of the Pian or a similar arrangement, or claims or d, Participants and/or beneficiaries ("Losses"), uniesS the Loss( 25E-37 of The section: entire in written hold it or and from, y prior by Plan directly. attfibutable to TASC negligence or willful misconduct. C. Each party's indemnification obligations are conditioned on the folio ing: t) If process is served, the indemnified party providing vritt n notice within five (5) business days of receiving service o process regarding an indemnifiable event; ?) If.the party receiving indemnification is required to lake any I admission or pay any consideration as part of a ttle ent, no settlement shall be made without such party's cone , and 3) Theindemnified party cooperating in the defense an 'ors ttlement of the indemnifiable event. Subject to the limitations et fe h:in the immediately preceding section of this Agreemen, the parties' indemnification obligations hereunder shall survive't u: tel ination of this Agreement. 11. Records TASC shall keep records and invoices in connection with the work to be peto ed under this Agreement. TASC shall maintain complete and accurate records with respe t to the costs incurred under this Agreement and any services, expenditures,. and disbursements" ha; ed to the i City for a minimum period of three (3) years, or for any longer period required b law from the date of final payment to TASC under this Agreement. All such records and in, oices shall be i clearly identifiabla. TASC shall allow a representative of the City to examine, a dit, i nd make transcripts or copies of such records and any other documents created pursuant to t its Agreement during regular business hours. TASC shall allow inspection or all work, dal a, dycuments, proccedin.-S, and activities related to this Agreement for a period of three (3) yearl froth the date 12 25E-38 of final payment to TASC under this Agreement. 12. Conflict of Interest Clause TASC covenants that it presently has no interests and shall not have inte indirect, which would conflict in airy manner with performance of services speci Agreement. 13. Discrimination TASC shall not discriminate 'because of race, color, creed, religion, sex, sexual orientation, age, national origin, ancestry, or disability, as defined and applicable law, in the recruitment, selection, training, utilization, promotion, termi employment related activities._ TASC affirms that it is an equal opportunity empl comply with all applicable federal, state and local laws and regulations. 14. Defense of Leal Actions TASC shall notify the Plan Sponsor of any legal action arising with respect I TASC becomes aware. Other than a regulatory claim that is defended by TASC w Audit Guarantee provided to the Plan Sponsor in writing from TASC, the defense shall be the responsibility of and be undertaken at the expense of the Plan Sponsor and agreed that TASC shall cooperate with and assist the Plan Sponsor in said def Sponsor's expenses, to the extent that the Plan Sponsor reasonably may require. 15. Limitations of Warranties and Liabilities A. Except as expressly set forth in this Agreement, TASC disclaims any; warranties, warranties of fitness for a particular purpose and implic merchantability. TASC will not be liable in contractor in tort for any or profits, or for any consequential, incidental, punitive, or similar da 13 25E-39 or this I status, sited by or other ad shall Ian of which applicable legal actions it beim understood .t Plan a'1 express arranties of +usiness I '.S! or, other than set forth in this Agreement, for any claims ofdatnages made by for any reason whatsoever, even if TASC has been advised of, had know, or in fact knew of the possibility of such damages. B. TASC shall not be liable to the Plan Sponsor or any other person for judgment or other action taken in good faith in the performance provided hereunder, or for any loss or damage occasioned thereby, or damage is clue to TASC's negligence or willAd misconduct. C. Notwithstanding -any other provision of this Agreement, and including breach of any duty imposed by this Agreement, including to the indemai fication obligations set forth above, or independent of t and regardless of any claim in contract, tort (including negligence) TASC's total, aggregate liability under this Agreement shall in no exceed 31,000,000.00. D. No action, regardless of form, arising out of the services Agreement, may be brought by the Plan Sponsor more than two the last services are provided under this Ag—cement. Each party these limitations of liability reflect an informed, voluntary alto parties of the risks (known and unknown) that may exist in cc Agreement. 16. 4foney Back Guarantee IFyou are not entirely pleased with the Plan, simply return all Plan po) days or the date received to obtain a ;efiind or the related fee, less the 5100 minimum fee. The Money Back Guarantee docs not apply to any TASC 14 25E-40 party to of the loss reason, limited der this the date ges that Teen the +ith this i witlin thirty Sen, ice Offering, to include: TASC ACA Employer Reporting, TASC ERISA, TASC HPA , TASC PCOR1, TASC Fonn 5500 Preparation, TASC Non -Discrimination Testing, and T SC , Iedicare Part D Notices. No refunds will be issued for these services. SECTION II In addition to the preceding paragraphs of Section [, the following terms shall be applicable depending on the Plan elected by the Plan Sponsor. 17. FlesSvstem i A. All claims submitted to F1exSystem other than substantiated copayint nts, iecurring medical expenses or debit card charges substantiated in real tim through an inventory 'Information approval system, or through 'other means compliant with Internal Revenue. Service regulations, must be substantiated by Inde end intI tnt third - party information prior to claim payment. If, at any po , the Plan S onsr makes the decision to adjudicate Plan participant claims, all claims and ubsti ntiation --submitted-to-TASC-by Plan be -forwarded -to -the Pl 1-Splonsor for- -- -- --- -- review prior to payment of the claim by TASC. If Plan Sponsor does not deject the claim within three (3) business days of receiving the forwarded claim, TAISC shall pay the claim. TASC reserves the right to request a deposit or p• ymept if the Estimated Claims Fee determined on the Application is, or is likely t be �ess than the amount necessary to process Plan benefits. TASC will requir a doposit or payment for negative Plan participant account balances or potential ltegakive Plan participant account balances upon termination of the Plan. B. Plan fees are the greater of the 'stated minimum or per Plan pan'icipan fee.! Fees are also calculated on the number of Plan participants in the Plan, includi�ig terminated i 15 I I 25E-41 18. employees. At the time ofib voice, the Plan Sponsor is responsible for, Imirlistratior fees for the entire Plan Year, including carryover or grace period, s applicable. Failure to remit Plan participant funds or payment For adminisirativ sery ces will result in a disruption of services, the forwarding to collections and/or t rmi aeon or all services providedby TASC under this Agreement. , C. FlexSystem is designed to administer HIPVI excepted and non -except d he•Ilth FSA plans. A non -excepted health FSA may be subject to HIPAA port bilit , a full COBRA offering of ,18 or 36 months, and certain of the health car reform. requirements under The Patient Protection and Affordable Care t, ;he Pian Sponsor who offers anon -excepted health FSA is respoasN foe urgng their plans meet all applicableregulations for non -excepted health plans. e a ditional requirements are not covered under the Audit Guarantee. TASC HSA A. TASC.progides administrative services to assist flan Sponsor in offeri g itj eligible employees the option to open Health.Saving Accounts -(HSA). Ian iSponsor acknowledges that TASC is not qualified to act as a trustee or custodi of dhe HSA funds and is not acting as such. TASC provides the Health Savings A cout#It (HSA) I services pursuant to an agreement with one or more third party Financi f institutions that serve as custodian and trustee of the HSA funds ("Custodian"). AS� is not i responsible for claims, damages or liabilities arising from failure of ustodian to perform its obligations or provide resources as required by its agreemei twit( TASC (Custodian is, however, liable tier failure to perform its obligations). W 25E-42 B. Plan Sponsor represents and warrants that, to tate best of its.knowle =e, nkc group health plan sponsored and maintained by Plan Sponsor pursuant to t hich medical coverage is provided to its employees electing to open a HSA with C usto ian will be, at all times relevant to this Agreement, an HDHP, in accordance wit Section 223 of the Internal Revenue Code of 1936, as amended (the "Code"). C. Plan Sponsor acknowledges and agrees that the HSAs owned by its e plo. s and held by Custodian shall not be employee benefit plans and the assets h din the HSA shall 'not be plan ;assets subject to the provisions of ERISA. Flan.lSponsor � I acknoMedges and agrees that at all times relevant to this Agreemeni part `cipanon in HSAs by employees shall be completely voluntary; and Plan Spot sor hall not: (i) limit ahe of participants to move monies In their HSAs to anotter HSA (except to the extent of restrictions imposed by the Code; (ii) Impose E ny conditions on the utilization ofHSA monies beyond those pennitted by the Code; (iii}represent or .advise that the HSAs are an employee welfare benefit plan t stab ished or l maintained by the employer; or (iv) receive any payment or co pen$ation in connection with -an HSA. Plan Sponsor acknowledges that TASC ma , R4 time to time, change the Custodian and may subcontract_ other aspects of TASC may not, however, require any participant to close an HSA 1withl the then current Custodian. D. TASC shall have no responsibility with respect to contributions paid; by Plan Sponsor, participants or other contributor or transferor to the FISAs othgr than to i allocate the contributions In accordance with clear instructions recei 'ed from Plan I Sponsor, participants, or other contributor or transferor. TASC hallihave no 17 25E-43 i obligation to take affirmative actions to collect monies paid as eontri utinl+s, such as, by way of example, to pursue a check or electronic payment trans Lr fi` m Plan Sponsor or a participant or other contributor or transferor that does no clew. If this I Agreement is terminated mid plan year, Plan Sponsor shall co tinuto be responsible For payment ofadministration fees set forth.in the Plan A Ipticlitiob for the entire plan year. Administration fees shall be calculated on a mil imutI or per participant basis, whichever is greater. For purposes of calculating ees on a per participant basis, the numberof participant shall be determined as of th invmice date and shall_ include any employees terminated mid -year. In adc itioto the administration fees set forth in the Plan Application, TASC shall also be a titled to i payment'from the Plan Sponsor of all expenses and costs reasonably ncuo•ed by it in the administration. of the HSAs, including, but not limited to, reim ursonent for i the cost of debit card. transactions. 19. TASC IiRA-NOT APPLICABLE JI I Fraudulent claims by Plan participants (regardless of whether by use of the d bit card, web submitted, TASC submitted, medical provider or manually submitted) and amount distiibuted to Plan participants that exceed the Plan participants' account balances are the Plan ponsot's i responsibility, unless the overpayment is due to a negligent actor omission on the artgFTASC. TASC also reserves the right to request a deposit or payment when the fund acro nt gees into a negative account balance. Fees are calculated at the ,Minimum Claims Fee ide tifi�d on the Application or enrolled tee whichever is greater. Fees are also calculated on the nu lber';ofhcahh enrolled in the Platt, including terminated employees at the time of invoice. The P an Sponsor is responsible for administration fees fin• the entire Plan year, including the run -out pc iod.,Standard 25E-44 l3 25E-44 nun -out period is ninety (90) days following the end of the Plan Year. In the event that prescription drug coverage is offered under the Plan and to the Plan Is an ERISA employee welfare benefit plan, Plan Sponsor shall be solely determining whether the prescription drug coverage is creditable or Medicare Part D purposes, on either a stand-alone basis or in conjunction with health plan. In such event, Plan Sponsor shall also be responsible for providing dis to Medicare Part D eligible individuals who are covered under or apply for covt Plan advising whether the prescription drug coverage provided through the Plan, alone basis or combined with another group health plan, is creditable. 2o. TASC COBRA -NOT APPLICABLE TASC and`the Plan Sponsor agree to the terms that are described in the Client Administration Manual (or the COBRA Client Adrninistration Manual -s if the Client is retaining TASC COBRA for state continuation), and accept the perform the functions that are listed on the Services and Responsibilities checkl are incorporated by reference. TASC. will provide appropriate notices to participants in a format and consistent with federal or state law and regulations pertaining to continuation. entitled to assume that all the covered persons reside at the address of tltc emplo) the Plan Sponsor, unless the Plan Sponsor provides alternative addresses. TASC i following deadlines, election periods, premium payment grace periods, COB requests, and Social Security extension requests. TASC does not have the disen Agreement to allow any exceptions to legally established deadlines. TASC will etaij i administrative fee charged to participants for continuing coverage. 19 25E-45 tent that Bible for rage for T group notices ider the a stand- 7ility to e Fonus that is will be ided by .itor the Alment :ler this the 2% The Plan Sponsor has the responsibility to review the monthly reports se' to he Plan Sponsor by TASC and reports that are available on line to ensure data has beenit mece ved and COBRA election notices sent. These reports are also notices indicating enrollmenchanges that are needed for participants, which can include reinstateents, terminations, andtan i hanges. The Plan Sponsor will make the necessary changes in a timely manner to effectuate overage with the applicable insurance carrier or third party administrator, unless an altemati •e a �rollment communication arrangement has been made and agreed upon between the parties..1 i cass where the Plan Sponsor is making the enrollment changes with the insurance cairier t' chlyd party administrator, TASC will not have any liability for any losses Including prem' m r claims payments due to a•Plan Sponsoes failure to make the enrollment changes when a enrollment change was communicated to the Plan Sponsor by monthly reporting or an alto ati a agreed' upon method. Incases where TASC has agreed to make the enrollment changes wit t he nsurance curler or third party administrator, TASC will not have any liability for any In es ncluding F premium or claims payments for a period beginning thirty (30) days after the enr Ime t change was communicated to the Plan Sponsor by monthly reporting or an altemativ agreed upon method. Plan Sponsors who are'small employers' as defined by applicable State law Inay,�under the federal Affordable Care Act ("ACA"), have a premium rating method that can inct de: age bands that may require mid plan year premium rate changes; a differential for smoking to accoproducts; f a differential for geographical location; and itemized billing by the Insurance rriei for each I person covered under a membership. Unless another method of administration is a reeupon, the Plan Sponsor will need to send to'TASC the actual individual rates billed by the iisurir for each 20 25E-46 person who is covered under the Plan (employee, covered spouse and dependents at, indicated on die carriers itemized bill) on the day before a COBR.A.L Qualifying Event, or State ven� if State I Continuation servicesare provided under this Agreement. This will be an additio .al data item required for the continuation administration, and all of the terms of this Agreeme it ad1ressing data submission will apply. TASC will not be responsible for any excise tax, peva ty, premium, or claims costs, due to failing to send a timely.Election Notice when the data fon ardel by the Plan Sponsor did not include the actual individual rates. The Plan Sponsor will n ify jASC of any mid -year premium rate change required'by the premium rating method when appll(cable .to their Plan. TASC'wilt-We no liability for any premium losses due'to the failurt to s6nd new coupons with the increased rate, except when timely notice of the change has been eceiVed from the Platt Sponsor.; 21. TASC FYILA-NOT APPLICABLE I The Plan Sponsor agrees, as is necessary for TASC.to complete its responsib litiel herein, to provide TASC with the following. information. The Plan Sponsor understands they are responsible for notifying TASC when .certain qualifying events occur, and that TASC can t cal ry out its responsibilities without notification as defined, with relations to the Plan Sponsor' emiiloyees. 1) Absences, or proposed absences, in excess of three (3) days from remdarly schedu Ied w1 irk for the circumstance (s) of a birth, adoption or placement in foster care of a child, the catsedlemployee; of h seriously ill child, spouse or parent, or the employee's own illness, 2) Eligibility of the prop employment by the Plan Sponsor in excess of 12 months and cumulative work hlut urs of 1,250 in I the preceding 12 months, 3) Notification to TASC if an employee who has been oft leave has i returned to work. The Plan Sponsor must provide to TASC and keep TASC currently it)formed, of i all pertinent information relating to the Plan Sponsor at the inception of the contra t and as may be i I I 21 25E-47 later modified by the Plan Sponsor, including but not limited to: t) Advise TASC (pf any changes in employee population per location that may affect FILA administration (incre se oi� decrease with relation to the minimum of 50 employees per covered location), 2) AdviseTAS ofany newly acquired locations, in order to ensure compliance with NVILA administration, 3) Aklviso TASC of any divested location (closing or sale to separate organization) [hat affects FIV[LA,mihistration, 4) Provide TASC with current information regarding all benefit progms; raprovi er'sl rates and other pertinent information. TASC and the Plan Sponsor agree to the terms that *e described in the FILA Client: Administration Manual (including State Family and Medical leves If subject), and accept the responsibility to perforin the functions that are listed in the above pi ragrIh. 22. TASC ACA Emplover Reporting -NOT APPLICABLE �II ACA Reporting requires the Plan Sponsor to make initial and annual determi atioiis, referred i to in the ACA Reporting Manual as "Determining Your Status under the AC.." TASC recommends these ACA determinations made by the Plan Sponsor and reported tol TASC be reviewed by the Plan Sponsor's Benefits Advisor, Broker, or Benefits Counsel. T re TSC Audit i .. Guarantee does not cover any 4930H penalties due to the failure to make accurate dete6riations. TASC is not responsible for any'4930H penalties due to activities that occurred, �r the failure to act, prior to the beginning of the Agreement with TASC. Complete infotmatioli onithe Group Business Plan Application and complete monthly data must be provided to T `SC prior to the tilteenth day of December so TASC may meet federal timing limits. TASC is nc res4onsible for any late filing penalties if this data is provided after December 15 of each year. 23. TASC ERISA -NOT APPLICABLE The Plan Sponsor agrees, as is necessary for the TASC to complete its herein, to timely provide the TASC with all applicable Plan and Benefit informa ion io include any insurance certificates, ASO certificates, plan summaries and the like needed f r incorporation i I in the Plan Document'Summary Plan Description. The Plan Sponsor will m ke apy and all 25E-48 determinations and disclosures as to their membership in a controlled group of eo rporuions. a group of businesses or trades under common control or an affiliated service gt't'up. The determination of whether such group can be included in a single plan document orlinultt1ple,plan documents and any resulting Form 5500 obligation(s) will rest solely with the Plan Spo sor. The Plan Sponsor is responsible for making the determination as to the tilinb of any 4 delinquent Form -5500 returns,.includingplan year for which any return is required a id the number of plans -in place during the period of delinquency. The Plan Sponsor is respo sibl� for the payment of any fines and penalties which may arise in connection with any of deli 9 ue1 returns, unless the delinquency status of a return is due to TASC negligence or failure to p rfb4 and all of the required data was delivered to TASC no less than fifteen (h) business da s prior to the filing due date. The Plan Sponsor or its agent will timely provide the informatio i necIessary to complete the applicable Form 5500 return, including participant counts and z ty applicable Schedules and or auditor reports needed for the completion of the return: i The Plan Sponsor understands they are responsible for notifying the TAC in]; a timely manner when certain plan changes occur. The Plan Sponsor understa, s than Plan Documents/Summary Plan Descriptions provided are lawyer authored bo' erplate legal documents designed to fulfill the Plan Document and SPD requirements under he Employee Retirement Income Security Act (hereafter ERISA). These Plan DocumentsrpPD� are not customizable for governmental plans, church groups or other entitles exempt firorrl ERISA. i Customization of the document is limited to a standard set of required infntmati anyl may not meet the needs of plan sponsors with complex plan designs andior Finding arrangetnengs or those requiring customization above and beyond the standard set of required intbmratiol and' 'at a level usually provided by contracted legal counsel. The Plan DocumentsrSPDs provide lotlibscopeof are kmitten for health and welfare plans subject to ERISA. Pension and retirement plans are outs this product. '' 25E-49 24. TASC PCORI Compliance -NOT APPLICABLE The TASC PCORI Compliance offering will assistyou in completing federal Quarters federal Excise Tax Rena -n. to report under the Affordable Care A t centered outcomes research (PCOR) fee on health plans. TASC is not a Tax Prep federal rules and can only assist you in completing the Form 720.The Plan Spons Fonn 720. 25. TASC HIPAA Compliance -NOT APPLICABLE The TASC HIPAA Compliance offering is intended to assist the PI establishing and documenting compliance with federal privacy and security rules HIPAA and HITECH. TASC is not engaged in renderinglegal or accounting s such service or advice is being offered in this product. When seeking such legal expert assistance, a competent professional should be engaged. If.you self -admit funded plan(s) and maintain medical records for claims purposes theft this produc you into compliance with the HITECH Security requirements 26. TASC GiveBack-NOT APPLICABLE TASC will place the Plan Sponsor on the TASC GiveBack Platform with In and any additional services as selected by the Client. TASC shall use ordinar diligence in the performance of its duties under this Agreement and provide timely and management of the Give Back Plan as outlined in the applicable product manual and/or materials incorporated by express reference to this Agreement. This Agreement for GiveBack will renew automatically. Either party may Agreement with thirty (30) days written notice. If services are terminated under it Agreement, the Employer will be responsible for providing any outstanding sei, under the Plan. 74 25E-50 mi 720. patient- ader the file IRS onsor in dated by and no or other our self- rot bring services and due tern}inate this required Either party may terminate this Agreement due to a default by giving the de aultilrtg party tcn (10) day written notice of the termination. If the non -defaulting party allowe A dirty (30) I day cure period the ten (101 day written. notice wilt be at the end of the period. SECTION [If This section applies to all plans. 27. Execution And Delivery i i The Plan Application is incorporated herein by reference and may be executed and delivered 1 by facsimile or Portable Document Format (PDF) transmission) in one or more co nteparts, all of which will be considered one and the same agreement, and this Agreerne it will! become i effective when the Plan Application is signed by a representative of the Plan Spor •or. Any such 1 facsimile or PDF documents and signatures shall have the same force and effe as frianually signed originals and shall be binding on the Plan SponsortPlan Sponsor and T. 23. Governing Law i This Agreement shall be construed,: govemcd by, and enforced in accord ince,with the internal laws of the State of Wisconsin without giving effect to the principles of �omity or I conflicts of laws thereof. i I 29. Entire Agreement i I This Agreement represents the entire agreement of the parties and supers des any prior i written or oral agreements. This Agreement shall not be altered or amended, ex ept tjy written agreement of duly authorized representatives ofTASC and the Plan Sponsor. 30. Attornevs' Fees In any action at law or in equity to enforce any of the provisions or ridhts under this I Agreement. the non -prevailing party in such litigation, as determined by the c xtrt In a final judgment or decree, shall pay to the prevailing party or patties all costs, expenses ind reasonable 25 25E-51 attorneys' and accountants' fees incurred therein by such party or parties (including! without limitation such costs, expenses andjees on any appeals), and if such prevailing party) "shall recover judgment in any such action or proceeding, such costs, expenses and fees shall b htaluded as part of such judgment. 31. Notices A. Any notice, demand or other communication required or permitted P belgiven to either party to this Agreement shall be in writing and shall be delivered by hand or delivered by prepaid courier -or sent.by electron c In fans. such as facsimile, telex or electronic mail. i B. Any, notice- personally delivered or delivered by courier shall be dei med(received t upon delivery. C. Any notice sent by electtoriic means shall be deemed received upt i thq date the I sending terminal confirms that the notice was received. D. The address to which communications shall be sent to the Plan Soons r is ;identified I in Section Iof the Plan Application. Either party maychange its ad ess by giving I i written notice to the other party as provided in this subsection. I 32. Assignment This Agreement may be assigned, delegated, or transferred without th prier written I consent of either party unless apartymakesareasonable claim that theperformancofobligations under the Agreement will not be honored. The assigning party will provide a rotic of assignment including information identifying die assignee within thirty (30) days of. thessiOnnent. A reasonable claim that the performance of obligations under the Agreement willIscribod ot be honored must be received .within fourteen (14) days of the date of the assignment notice in this i paragraph. Notwithstanding. such consent shall not be necessary in the context o lan acquisition by asset sale, merger, change of control or operation of law. This Agreement shaI be binding on 26 25E-52 any successors, assigns and subcontractors of the parties authorized under this Ag 33. Waiver The failure of either party at any time to require performance or obscriam party of any term or condition of this Agreement shall not affect the full right t performance or observance at any subsequent time. Further, no single or partial right, power or privilege will preclude any other or further exercise of any other 1 privilege. 34. Severability If any.term or condition of this Agreement is held to be .Invalid or unenforct of any statute, rule of law or public policy, all other terms.agci conditions of this A remain in full force and effect as if this Agreement had been executed with unenforceable portion eliminated. ATTEST: CITY OF SANTA ANA MARIA HUIZAR Clerk of the Council APPROVED AS TO FORM: SOMA R. CARVALHO City Attorney CYNTHIA KURTZ Interim City Manager RECOMENIENDED FOR By: - Laura A. Rossini ED RAYA Senior Assistant Cit/ Attorney Executive Director of Personnel (Signatures continue on next page] ?7 25E-53 by other e such of any 1wer or reason it shall or TOTAL ADMINISTRATIVE SERVICES CORPORATION (Name) _SVP lArS _ (Title) '3 25E-54 EXHIBIT A PLAN APPLICATION ?9 25E-55 9,,1R, Group ) Company Name: Clef of Santa Ana Business Federal IDk EJ TASC Suite K (1-8) ladaded 9&deg berme ilikf CA Business Planp licatlon _ .. _ _ _ , _. _ , NAILS/SIC Code Total If Employ es O TASC Form 5500 Preparation 972 Mature of Business: Cly Government Total k BeneFit Eliglh _ _. E a Em(�loyees zas lnrernor Use gnry: Otarge Olent quallller qJ •-.._ ❑ then 1 Health Insurance Carrier. CeiPER.S Medical Carrier Group IDk: 483399115e ene IDate: Na ! ,._.— Email .._ Fax _... _ :ti! 11 Please submit completed Applkationwit ❑ TASC HSA -Plan Only T,15C, rJo ew Bu IAass Department gone, required fees to: ne*buslnessetzsconline.com (E08)'661.5638 23021ntern Clonal P.O. Box 11140 LontaetName: Ca'doHanes Email (m Uanes�sana-a Title: een�RtsB Ca mPensa9an9upeMsar Telephone .(713)847-6967 dg ) Company Name: Clef of Santa Ana Business Federal IDk EJ TASC Suite K (1-8) ladaded 9&deg berme Physical Address: (no PO sex) 20 Chic Center Plaza 1134 City: Ana. State CA Zip 92702._ _Sa_n_ta Maitin Address:fnarroBOX J Lib/: State Z ip: _ .. _ _ _ , _. _ , NAILS/SIC Code Total If Employ es O TASC Form 5500 Preparation 972 Mature of Business: Cly Government Total k BeneFit Eliglh _ _. E a Em(�loyees zas Tax Filing Status ❑ C -Corp ❑ S -Corp ❑ Partnership ❑ Sole Proprietor ❑ Non Profit ❑ LLC ❑ then 1 Health Insurance Carrier. CeiPER.S Medical Carrier Group IDk: 483399115e ene IDate: Na ! CamierAM/Rep Name: ;wane Flelda AM/Rea Email: , y9elds(dkeenan.s I Are you a current TASC Client? Rtlo ❑_ Les_t If yes, please provide yaur_L_2-Digit_TASC IDk. Name existtng/active TASC services: Select the new TASCservice offerings) for this application (and complete each corresponding section under PAT 63: I �` Check the hwerjorearh A TASCSuite Add -On Offerings(apdonaj:Complee app, :ection for :electi ons EJ TASC Suite K (1-8) ladaded 9&deg berme O TASC ACA Employer Reporting ❑ 7AffRA _ ❑ FASC FMLA ❑ Eligibility Deterrldnad _ a complete cans scathe❑TASC Non-Diserlmihation Testing 0TASA Transit Account SECTIONA Morin this appamtion. O TASC Form 5500 Preparation l Cd Parking Account BENEATACCOUNT MANAGEMENTSERVICES BENEFIT CgNTINUATION SE vICESj SECTION D H El FlexSystem FSA` ❑ TASC COBRA ❑ 46 rakecver_ U FlexSystem POP _ ❑ FASC FMLA ❑ Eligibility Deterrldnad I SECTION E Transit Account SECTIONA --. ; .___..:.. 't_ .,..:__...._ ..--......... _, i;0ii1PLIANeEs6`RVit'_._.. . _ Cd Parking Account ❑ TASC ACA Employer Reporting f2-Prc atrac J SECTION F O TASC HSA -Full ❑ TASC ERISA I ❑TASC HSA -Limited SECTION ❑ Medicare Part DNodcas ❑ TASC HSA -Plan Only O Late 5500 Filing ❑ PPACANotices iSECfIONG ❑ TASC HRA -Full Cl Carrier Certificate Ci Add Wrap Doc(s) ❑ TASC HRA Debit Card SECTION![ ❑ TASC PCORI(with TASC ERISA -free) • TASC HRA -Self C) TASC PCORI (without TASC ERISA) j SECTICNH ❑__TASC G)veBack SECTION 1 O TASC Form 5500 Preparation l SECTION 1 C] PayPath° 'camprams araea m ❑ TASC Non.-Cliscrinfination Testing SECTION) ❑ TASC Funded HRA' Pion epP71-odan- i ❑ TASC HIPAA SECTION x Enter each Service Offering selected In PART Z and the applicable fees in the pricing chart below: New Service Offerings: — One Time ,. Administration Min WDM go-_. ,._­__ . _ FlexSystem FSA t3C9 .$14,25 .$;100 FEES: Page 3 *3913-010117 Fees �. S;a.25 I Employer Initial �IVASC 25E-56 Emial oyer Initia 'ITASC TC-3923.Moll! 25E-57 full R M-0 - select a payment method for your fees due and complete the following Information for the selected payment mc:hod. Payment Method Options: _iCH (E-Pay)l Credit Card' Invoiced —M. I Set -Up Fees: N/A I DUE NOw for all services Admin F cas DUE NOVI for. TASC H AA.FCA, POP, Self -HRA Administration, Renewal, ERISA and Additional Fees: ALL FEES DUE NOW for TASC I 1"Information —for Payment e­th_0d5__ �_,_,_�__�__�.. 'CA --.i •••---••---•• Financial Institution Name: JP II -raw Clauaca, State: ACH (B -Pay) Information: Bank Routing 0 (9 iff-03); =71n? Checking ACC it: . 65.195 2 a7s &_ ng anduaccumf numbers are typrcaflytootad at the bottomieltoomarof a Munk chockfrom "a urbankivaa.). ..The routing num_bera alway_t nine fsf diplts long and encfafe0byrof�ns.� _ 1 El MasterCard Q Visa 0 American Express 0 Discover Card R: Eq. Da.t.e:. Credit Card Information: ,lame on Card: W Signature: Frequency: a Quarterly Cl Annually (1-15 Employees default; to Annually) I ZI same address from Section 1 0 Different address: invoice Information:Pilling Contact Name. ' Mail to: .Email: � Street Address: City zip: rE.PayIYTASc,s standard method forsubmission I t.s C C no, Imply eu, complete the box above, signing where Indicated. Please note ACH information for each benefit's plan funding will need separate arte fan 11. mspectivesection I agree that the Paver my revoke the authorization only by first nourying the 0 of the application. All wdreo debit authorizations mus. the 62(ifiVitIO 111, qina In the manner Of C tnatflamissaPorIGO specified In the authorization. The language In the authorization represents the disclosure requirement associated with policies upon ACH NetMel PartICIPWItS. 'Credit Card payment option is only available for fees submitted with this completed Plan Applicadom Ifis not ariallableforfuture billi I PsYnients. This Group P ble, the company or service of the se Level Agreement You also accept [he TASC HIPAA Privacy offering as indlcatedin PaK 2 above for applicable serrice oEfrings HIPAA Business Associate Agreement signed by TASC that assures compliance for` and you our refords. adInowledge receipt of the attached Further, you, SC and/or its In Feed subcontraCto r its Information") subcontractors or agents use and disclosure of Clalm.Feed Information shall be subject to the terms of the Business Asz d2te)lgreement. IMPORTANTNOTE: TheTASC ACA Employer Reporting term will continue for a 12 -month initial term, thareafterren ving btorratically for one I year terms, Early termination fees are described on page 15, under Termination and Ravaevraf of Agreement. I have raid, understand and agree to the terms a ndcondifilons; stated in this Group Plan Application, the Service Lev, I Agreement, and the Business Associate Agreement (it ap�cabie) ttasted by the signature below, effective on the date of the signal L a. 0 Employer Signature: Date: Title: Executive Director of Personnel )§ervices Jmy CP cs�l a 1-4709-1480- Distributor/Agent ributor/AgettNanna: Keenan & Associates 358 Retail Co de: Primary Account Rep Name: kYvette Fields Email: 'yrields@ke nan.com INTERNAL USE ONLY: Assist IvlVTASC ID; Emial oyer Initia 'ITASC TC-3923.Moll! 25E-57 To conclude this application, please complete each Section below for the service offerings selected in PART For a TASC Suite, complete each section for the service offerings Included in the Suite. Select the FlexSystem Plans) you are applying For and enter the requested informadonwhere Indicated for e4ch Selected Plan: _— • Set -Up Fee fd 4 nowi UFlexible $pendingAccount(FSA)Full Administration PRIC)NGINFOI • AdminFee-Pr participant, per month 11 . Annual Rene Fee ( Ell Premium Only Plan (POP)Administration .PRICINGIINFO: •AdminFee-praroup, peryearilduenow) I T^- Naodditional C3Transit f2elmtiurseinent Account (T/P) . eew•I/pfexSystem Fu11F5A I. ---- PRICING INFO: •AdminFee —p rpartldpanp per month ❑ParldngReimbursement Account (T/P) . Annual ew Ren IFee PLAN INFORMATION_ — Full FSAL POP Transit Accou t Parking Account Number of Eligible -Employees (each): i ❑ No fl Yes ❑ Na ® Yes 3 No Cl Ye ( I H No U Yes Existing Plan In Place? ' i - . If YES, please complete the fo)lowing: . 1 -ERISA 3 Digit Plan g:_ I NJA :NIA f R of Current Participants: 135' 135 Name rre IL Nae of CuntAdministrator: canals [[ Conaxrs — PLAN OPTIONS_,_ F -S& TJo o --Select options below and enter the information for your Current Plan — N Plan [.applicable current and new Plan(s):.. fj H Healthcare FSA Carryover (defauitssco) Carryover S: Carryo _•^•.- ._ er5:1 �--,-- 500 ❑ Grace Period fdefoult2.5manrhs): 1i8ealthcuoyover6 I ^---r -. GP End Date: GP End Date: _ _j_j_ .. 0 eler:dd, Health wRl be euludedJmm Gmml'eripd. (_ _ _f_/_ a15 El Runout Period fdefauft3a dayrafterPlan End pate)—f-1-- RO End Date. , RO End - ate: —1_�— eunbutforollbenefluendons6me date Select administrator for Curren FSA Plan Grace Period and Runout: ❑ Prior Administrator 3 T Cs 4NIPORTANty0brelo theflosystem TakeoverCheu'iAJorlryormotlan rhvtmvsrberecelvedW.Pone Plonsraridare with TASC ongave alujifamrprlarAdminaaurar must be provided m TASCe@ee the pdorPlon Year Runouthds ended yAth the opplmblefa dtng. II 3 Healthcare FSA -Medical Expense Reimbursement Account! $!Eon Maximum Election (Emploee & Fanily) is employer-sponsored group health Insurance offered to employees?R)Yes ONo>>TN0,youarenctef "bletoito�Rerthlsbenera. 03 Dependent Care FSA Reimbursement Account: Maximum, $5,000; $2,50 olfmariiedfilingseparately(Empi ee&�amily) B Ndn-Employer Sponsored Premium Reimbursement (NESP): For qualified Individual Premium Plans not "eyed through any employer. Is employer-sponsored.group health insurance offered to employees? ® Yes O No » /JNa, youarenot at Me toloffer this benefit. 3 Medical or Medical -Related Premium: Group Sponsored (Employee & Family) 8 Voluntary/Group Term Life Insurance Premium: Up to S50,0001n death benefits (Employee Only) Id Disability Insurance Premium; Pre -taxing employee contributions. -Will make benefit taxable compensation (E ployer Only) KI Supplemental Insurance: Includes cancer, hospital confinement. Intemive care. accidental death and dismerrerment (Emplovee & Family) 8 Medical/Office: $ 5ti $ r"' V Prescription Drug: Defaults are bated on the current Transit Account f Parking Account i'-------------- -- -----I I Terntinal Restricted Card 3 Rollover 7 Reimbursement Restriction: ; 3 Rollover ❑ Reimbursement Restriction ( pages (o burl Tmnsir undPnMny) _ Days hRrda'aulr) Days hap delaury q i j — --'— Pace Employer Initial Gi/2" QgIjVASC ic-3923.410tt] i 25E-58 PLAN CONTRIBUTIONS 7 i rFSA� 7!P •.E Employer Contributions? @No❑Yes ,. Payroll/Funding Cycle (select ane.): El Weekly ❑ Bi -Weekly Sam! -Monthly ❑ Monthly � '❑'4thee t it Lontributlons In 12•mo Plan Year: i Dates applied to Participant accounts based an above salad all dpay}cycfe. Participant Contribution Schedule: VContribution: '� �)-y 2''° Contribution: ��j�%% Las Coa[tibution: )J�%% (hosed on Plan Funding schedule beloiv/fir the EstimatedDuteofAecciPtfEDn)) Other cycles: FSA ,POP T PARTICIPANT AND ELIGIBILITY R_EQUIf;EMENTS •_^ - select the employment requirement below that an eligible employee must m :at in grder to enroll in the Entry and Probationary Period: FlexSystem Plan at open enrollment, or atthe time of hire: ❑-On the date ofhire ❑ Vaofthe month after dateofhire E) 30 days after date of hire ❑ 1't of the month after 30 days of continuous employment i { ❑ 50 days after date of hire Cl 1" of the month after 60 days of continuous employment O 90 days afterdateofhire Cl Other kricludeo Excluded NIA 1 ❑❑ �, Members of bargaining units, Additional Requirements: p ❑ Part time employees re ular r/ scheduled to work (selxtal[thatappty)_— '❑' ❑ r❑ -i Seasonal employees regularly working at least t least hours per week wit hina year_ ❑ ❑ 141 Employees under years or age - -months - PLAN START_-_ '•-„�,. _ _ _- _,_ Flexsystam ddministrado tFSA __ Poe T/P, begin4 Select and complete one oft Oft, optiansto md:cate Fhe Plan Year and when ❑ Initial Plan Year(na prior Plan Fists)_ 0 Year Administration_ 2n° fid Sttc esslve Years w� ,41(mo/yr) Plan Start Date. First day of: (mo/yr) Firstdayof 9 Consecutive Months Conn_ ued: Tw ve (12) month perfad - Note:Plans need not ran an the calendarye_ar (i.e. mnuar 1. December3l) t O Renewal Date A_dministration (TASCadministmtion begins on Plan renewal date) Plan Start Date: day _First Consecutive a Months Continued: Tvielve (12) month period ____ , _ __•,•,j__ -,,,._,e,,,_,_,_„ -..._„f Mid -Year Plan Takeover Plan Start Date 1 Current TPA Plan at at zan (mo(ddI'/fI °0 Plao End Date 61 - 2d1r_ {mo/did/yrJ TASC FlexSystem Plan: as at 1 7 (mo/dd/yr) - _ _ - PLAN FUNDING �--�_,,,,,,._. i Fs�_ TIP This Scotian defines the Estimated f7dansFee (ECF)method utilized to make benefit payments to your FlexSystem Pan:ripants ECF 11c Mediated by determining the total contributionsforthe Pian Year(employe,andemployer) and divide that total by the number of payments scheduled un If the total ECF collected for the Plan Year r 'ECF iYpectedDate P)gecalpt tufts inti excess fees greater man +(ED11). this fee is adjusted as appliableformid-reorenrallment and election changes. paid claims for that Plan year, the excess will be returned to the Pian Sponsor is forfeiture under the Plan. Any fees ar Chargesde 'itlh this section are in I addition to the fees due underPart 2: TASC services and Fees. bank�information: To start this process: 1) choose Funding process, (a) vers your Expected Date of Receipt, and (3f enter you _ 53 TASC ACH (default): TASC initiates funding paymentvia ACH on the EDR. I �(1) ❑ Client MVTASCFunding. client initiates funding Payment via MVTASConorbefore the EDR.Note: Underthisatian,T{iSCwilluse•rourAccount s{ and Rcuting Numbers to post any unpaid funding amounts that arson(1)business y past, he EDR.Ako, additional f annual fee.will apply if ACH is not elected($10.Coper payrq!ll. (2) VeriP/ your Expected Date EOR is the payroll contribution schedule Indicated in the PlanCpntribudansectionto that TASC-will poll an Auto ACH from your designated account and apply the payrolls intribulions f each palyrdll cycle. Thlsls the date to year Pariclpant's I of Receipt (ED R); amount(s), This may or gigynct be the mune dote as the ?a rd cOcat's Payroll deduct? ndotea f(3) Sank Information: ❑ Use same ACH info from Part d of this Application ❑ Use different CH InformStateation as per below: i I Financial institution Name: : 1 f Bank Routing Plumber(9 digits): Checking Accou t0: _ ADMIN ONLY: FlexSystem •Special Instructions: T t "Toss Pagea Employer initis S( tGi927-0tJ' ❑ 25E-59 ap'k 'r„�-+Y.q`u�-, .r'� 7 O 1,' '� , �`• ..t yam' � a f ..•h M1 �'.,.iV ,.r..�ac.n -`_., ���r,%+� Select one TASC HSA Plan to apply for and complete the requested information for that Plan Type jos noted y Foriler tabs): ' j'• Set-Up Fee (duenaw) O,H$AFullAtlrnini5trailon �__- PRICJNGINFO ,Admin Fee-perpartidpanI 1 perdonth -TII ' • det•Up Fee (due pawl O HSA Limited Plan Administlation PR(CiNG1NFO aAdnilNFee-perparticipener ' iet•lJp Fee (due ndwJ � manth(No Minimum] ❑HSA Plan-Only Administration PRICING INFO No Admin Fee . PLAN INFORMATION uii juMltEo I PtnN ONLY Number of Eligible Employees Exlstmg HSA In place? ❑ No 0 Yes I _ ` Existing Health FSA In place? . 0 No 0 Yes 'Cl Limited Health FSA i fjYES, Indicate the Plan Type: 0 limited Post-Deductible Health FSA O General Purpose Health FSA +Limited Health FSA ❑ General Purpose Health FSA+ Limited Post-Dedu It tible ealtn FSA date than your existing Health FSA then youustamendyour endre Veal Note: Ifyou mplementan HSA and different Planerecdve -m FSA to Limited0.UmitedPost- Deductible Health FSA.Amend the Plan trydovmloac'ing and.completingthe adoption of the TASC Plan Document as Instructedlnyour eltom Xlt moved to lheamended Health FSA The IRS will not allow mid-year Participant election changes. Atyournext open enrollment you can derif alih FSA options. PLAN CONTRIBUTIONS. _�^ - I_�TFULL LIMITED" R of EE Payroll Contributions; Payroll/Funding_ Cyile: 0 Weekly 0 Bi Weekly 0 Semi-Monthly 0 Monthly .. a 9ther: ' - Dates appbedto Farddpant acdo'unfs based on dba6esdec edpoyrafi cYJz:_ Participant Contribution Schedule: 10 Contribution:;_ 2"a Contribution Jam— Last botri�ution: _f_/_` 1 Employer Contributions?: 0 No 0 Yes If YES please complete all Information below. Contribution Amount per Coverage Level: Single: $ Family: S _ ._ ._ ... Frequency of Employer Contributions: ❑One Time: . Contribution Date: 0 Weekly 0 81-Weekly 17 Semi-Monthly ❑ M nth(yi 0 Employer Contribution Schedule: VContribution:Contnhutio : _J. I For ban kingtlolidays,selectaneoption:❑AppfycontnhuticnsnextbuslnesYday ❑Apply con[ bubo spriorbus_ine_ssday �No❑Yes IfYESselectamethodbeloi4: f _ Pro-RatedforMid-YearEnrollees?: 0 As of Plan Start Date 0 As of.Most Recent Quarter Othi PLANSTART _ _ _ Fut. unuteo LPCAN aNLY_j Data:�- f_,4 mo/cid) HSA Plan End Date: _/_ .(rooldd)-ifopplkable� HSAP�E r .f1 PLAN FUNDING _ - i l FULL Tofund your HSAPlan, TASC will initiate ACH debits from the bank account and Bnoncial Institution named belosd. Pan fun int; payments will be eledronialfy deducted from the indicated bank account and automatically submiGed bn�your scheduledpayroll co tdbuti n dates. Bank Information Q Use. same ACH Info from Part'4 of thls Application_ C2 Use different ACH lnforme on asiper below: Rnanclaf Institution Name: Branch: Bank Routing Number (9 digits): Ch_ecking Accou tg: I - _ 0 1 understand the pay dates can NOT be changed once the Plan is enrolled. 0 I understand TASC will send an email prior to withdrawing funds for my account and that 1 should to act T> SC with any changes no later than three (3) days prior to the employee's payroll date, Disclaimer for a standalone HSA Plan (not combined with TASC FlexSystam):TASC has dereIoped a service known as "TASC SA",Illat• provides full administrativeservices lcnHeaith Savings Accountz Itis understood that the. client wishes to add the HSA to its current Secti 12S 11an and that the client acknowledges they have amended their section 125 Plan to include the required HSA language to allow HSA Contributions to a pre;trated and their Section 125 Plan Documents and SPD's are current according to Federal Law. I ADMIN ONLY:TASCHSA-Speciallnstructions: ,�—� ~^� y Page5 EmployerinIna _ gI� TASC Fd921-0lalt7 _(_U 'u 25E-60 r -. tar Char Pian 7voe (noted by Set -Up Fee (due, ow) ' - 0 TASC HRA Full Administration ,. PRfCYNG , •Admin Fee ---per arUcit}ant, per month Additional Serulcesr _. IWO:, , i Annual Renewal ee �. - (3 TASC Debit Card (included at no. charge for First Dollar Plans) - + Based an numb of employees Single •$4950; Pom0y-$t0,CC0 ING ' No SeWp Fee —!" $ 0 h Member (imbeddeddeductible) .PRI 'C) TASC HRA Self -Administration INEOt • Admin Fee -per roup, per year (due now) • Annual Renetial ez .. . .. _ PLANINFORMATIONINFORMATI~� � ION FULL sets Estimated Numier of Participants: Number of Employee; (FT+PT) to determine G41SRepordn Re qu/ emem. EX'i-stlagHRA_Pn_PI lanl_acet El No ❑Yes If YES, please providethefo)iawfngfnformation: - ERISA 3 -Digi[ Plan 9: — R of current Participants: - Name ofCurrent Administrator. Current Run -Out: Period:.. Days _ ,.Who will administer current Plari Runout? 11. tj rior no 0 TASC PARTICIPANT AND ELFGIBILITY,REQUIREMEM -` I _yFlits sEIF Selectooe eligibility, requirement below• -- 0 Eligibility requirementsinclude partidpabon in the named Health Insurance Plan fN/Afor Qualified small fmpla. er NRA Plum), or :0 Eligibility requirements include (select df)that apply beoW):- ' O Parttime employees wording at least _hoursof work perwee4 will be Ind uded(maxiinum 29h urs) O Current employees completing_months of service with the employerwill be included (muximuqr 90 d�7s) LO New employees completing_ months of service wit the employer will be Included (maximum I days D Eligibllib/ requirements–OTHER: PLAN DESIGN FULL sEtF t Each Plan Design selected requires a separate Plan Appllwhon. Admi9istr4ticn fees erd funding arrangements apply a each p Application. HRA Plan Design options (select one perAppfication)Bud etPlan Fund(ng_ The TASCead tPlaFunding Fee is calculated❑ Plani Medical Deductible Only_ At 25% asapercento the a�re.gate annual benefit ❑Plan 2 Medical Deductible 9 PrescriptionASSD'! under the rA6 HRA Ida. To colculareplan (aRo appbes to Deductible Only ➢lout pre:alptiaas appl7 eowordJhe deductlbfel funding take 7 itail Exlosure r Funding %/12 0 Plan 3: Medical Deductible & Co Insurance At 50% months. O Plan 4: Medical Deductible, Cc -pay,. At 50°% Ifycu do nits a 7oaGdesfred Plan Design, ❑ Plan 5, Medical Deductible,_Co-Pay, Co-insurance, & Prescription At 50% please call TA ati§P0.422,4661'to discuss 0 Plan 6: Uninsured Medical (must be i_n_tegrated with GHP) At50% Plan setup. ❑ Plan 7: QSEHRA Uninsured MedicalAt 50% 10^ Plan 8: QSEHRA Medical InsurancePremiums At75% 1 0 plan 9 QSEHRA Uninsured Medical & Individual Insurance Premiums _ At 7576 TAs6 HRA Pian Participant Responsibility:..Individual: S - Cl 6 (amauntpartlCponN; respcnslbfzforpdor to reimhursemertsl _ ram fly Maximum: S 0'b Percentae OollarAmounc Range TAS: %i 5 "$ ;$ Member (embedded deductible) Famify Aggregate HRAEmmolaver Reimbursed TASC HRA/Employer Reimbursements: Regulotory lunits Jar QSEHRA: - $ 5 Single •$4950; Pom0y-$t0,CC0 -�'-y-=--• Max. reimbursement per Individual: —!" $ 0 h Member (imbeddeddeductible) Aa,° 0 b/FanilYAP-Melte Paae a TG]9!]03a! V 25E-61 Employer Initial i I .ase? Er!oleyer Initial •.tl��rTASC Tc -M3 010117 I 25E-62 FULL SELF �I�ect and complete one of the foilowin brroo tions Indicate the .Plan Year dates and when TASC HRAadmin_Istration begin?. Cl NEW HRA .Plan (no currenrplan exist^) i'�Year AJministration 2eda d'Suc arrive Years o: _ (mo/yr) Plan Start Date: First day o_f: _j_y (Mo_/yr) First day V Consecutive -Months. Continued: Tivel a 112)month period Plate. Plans not run on the calendar year Q.e. la --Decemb&31). _ _need 0 Mid -,Year Plan Takeover -select one setup option below(Yenrto-nate balances must be subminedwlth enrcgments •u-cry/ l alder YlIo� be entered)+ OFUIIPIanYearsetup;or Flan Sponsor mustsubmitanaggregatebalance reportcfpoid(Pant oimspaldyearto-date to,pdJust the Padidppnt HPA balance 0 Short Plan Year setup: (fess than 12 months) Plan Sponsormbstsubmiton aggregate deductible credltrepo- year-to-date to adjust the Paiddpunt HRA balance. Aifaws you alpan/npantdalmspold o e#e d o deductible credit td your Participants based an the amount o/ the heplth_insinim" ed"' lethathasbeen satispedthusfac �_ —Enter plan Betas based on yowseletted setup: Plan Sart Date �� Plan End Date Current TPA Plan:.- _/T/ .. (mo/rid/jry _j = (mofdd/yr) TASC HRA Plan: _/_j_ {mo/rid/yr) i _ NIA f PLAN FUNDING T To fund your TASC HRA Plan TASC will Initiate AOl debitsfrotn the financial institution and bank accountnamed bet r I �anhlnformation ❑.Use•sameACHInfofromPart4o_f_thisApplication_ 0 VsediFemntpC'Hinformab)nasperheiovr. Financial Institution Name Bank Routing Number (9 digia).1 Checking Accoun 9: I — ADMIN ONLY! TA5C HRA - Spet)al Instructions: "- Funding: _ % (Minimum of 25%) x., � 4 .,, J .tL��YF•s*,ai �� 0 t a - 'b. is : .rxr' . �.4 s -SEL.. O COBRA Admtnistratfon & Compliance • Se NOTE: fie Premium Collection FOIm fsrequlred wtth completed uppficotfon;efare Plan titin be tetap. •. __. . .. -. PRICING • Ad Lip Fee (due nowt I In Fee -Per HE, Per month Additional Serviee5 (addiefongl;Feesapply):. - ., .... INFO: • An dal Rdnewal Fee ❑Takeover QuaRaed BeneHdarles (TCIe) COBRA Enrdiiees Ba zd on inumberof employees f5vtmi[7akeoverQuaflJtedDeneJJdor/Farm�foraachiTQB with mmpletedappticoticn)^✓- _ ! ^__ PLAN INFORMATION Number Employees an Healthlnsurance Plan: Total Number of Employees (pro-ratefar PT): f (Carreatcountneededforbillingpurposes) Current COBRA Administrator. 0Self 00 er - _ ^. or DIVISIONS �_�� _ _ SUBSIDIARIES, AFFI-�T __ I -._•T___ _- ,UATES, Identify all subsidiaries, affiliates, or divisions to Include under TASC COBRA and if they requlre a separate setup far ervice�communica8ons: Name: Separate. Name: Saarat. i) 0. 3) i7 2) JI 0 PIAN START �•—� ___ _ i j Enter the month and year that the Plan Year•Mll start for theirst year c f TASC COBRA administration: ( 1 f TASC COBRA PlonappFcation mus: be reeelvedby 15th ofmanth rim' Fart day of: froplr) to this startdete. _�_ CDBRAP.ddepdum Sneadadifrequestedpinn startd to Plan Start Date: doe; no!nreetthls requirement. f 1 OFirst of month, following qualifying event O Other(precse sped); below+: , COBRA PMod Begins: C1 Day aFtzr.quali-tying evert. _ I _ ADMIN ONLY: TASC COBRA - Special Instructions: I .ase? Er!oleyer Initial •.tl��rTASC Tc -M3 010117 I 25E-62 Contact Name: 1 Email: 'D FI i ' ,J Per Payroll File i 4... 'R`„�'S.'h] T �1-'_.rSI.C. W.il. .. .mYj•F+_L.'��'��t�' °�i4L�J.1rFAli . ...�.T'..,i%3}'�'*['.R YY ALE Status Information ]�--- -- _-,�---_--- -. -_-- - -.-- ..----.---_. ❑ ALE with Insured (Medical Plan ! Applicable Large Employer (ALE) Status: Q ALE with Self-lnsured Medical Plan • Set -Up Fe. &Compliance /doe -�own �Z�iy.�y.'.L. / u ❑ FMLA Administration , Admin Fe ;PRICING - peF• mplayee, per month live Minim Additional Servmes(ad�tlbnvlfees apply). _ - INFO: m) ❑ FMLA Eligibility& Entitlement Determination gree of charge within a WCsviteJ • Annual Re LSelect one: ❑ Submit eligibility (Ile permanth ❑ Submit eigibflity file per event _ ewal ee -. -••-I•--^.•^^------•-• ❑QualifyingOFFer Nle!hod ❑ S3';'S O McCrod ' PLAN INFORMATION i _ __ ---- .. ----.- •� Number of Company Locations: .or Page Employer initial Number of Employees: tc.sa;l mau: Number of EES currently on FMLA Leave: Enter Location Name(s): { .(oddiNonolfeed apply per takeover a[ implamantation) _ Current FMLA Administrator(enrerbevaw): ) Enter anystates doing commerce: ❑FMSeiP O TPA: I Reporting per Location?: ❑ N ❑ Yes'(nextgaesaon) _ LA to run concurrent with Porkers O, yes if YES/enter locations and contacts: I Compensation and Short-term Disability Plans: Cl No O Manual Report(viaonifnefarm) i Method of Reporting FMLA Hours: 0Data Feed (via recurring6(efrom yoGr timekeeping syste forFMA time use d) } ollmg BackwCalendarYear ❑ Aard ffINIA12-monthTracking Type(se%pt ore): QgolhngForward t]Plan year vv/StartDate of J_ daysprlarto this St tdota TASC FMLA'Plan Start Date: - _J=(mo/dd) 'P'anapplicadon miurbe mceived 10 �_- ADMIN ONLY: TMC FMLA -Special Instructions: j I - 1. .t�� �`---_•t PRICING ' Set -Up Fee (duen w) ❑ ACA Employer Reporting (2 -year cantract required)• Annual Admin Fee •INFD fdue:r(ow) (employees , Based on number REQUIRED: Please select your Employertype and the appropriate service offering selection for your ACA Re_por Ing needs: Ent vel �. Le vel ofService Needed .. Hou, Tracking) ❑ Single ALE or Government Entity (one EIN): ❑ Comprehensive Plan (includes Voriab _ ❑ Reporting Qnly Hour j Tracking) ❑ Aggregated ALE (more than one ON): Q Comprehensive Plan /includes Varlabi Controlled Group or Government Entity ❑ Reporting Only ❑ Non ALE (under 50 FT employees): Employee Mandate Only _ IT Employer Inforinatioh`^ Contact Name: 1 Email: 'D FI i ' ,J Per Payroll File Tele hone: !File Frequency: iMonthiy ALE Status Information ]�--- -- _-,�---_--- -. -_-- - -.-- ..----.---_. ❑ ALE with Insured (Medical Plan ! Applicable Large Employer (ALE) Status: Q ALE with Self-lnsured Medical Plan ❑ Non -ALE with Self -Insured Medical Plan (10948 and 10958 Filing » nol furtherihfo needed. -- - -- -- —.. ,.-_. .�-__._._.... If you are a `NON AL"" with Self•Ins -gd M=d' I Plan. you DO NOT need to arovide the information belrw- Plan Information and Services Please indlcaf whether you will be Including in, op ionai services baler (response requlrad for pricing): _ I i Variable Hour Tracking: ❑ Ye_s ❑ no Minimum Essential Coverage offer indicator: ❑ -1Fs ❑ No ! The rASCAC9 Emplayer ReportingAdminis:radon Manual will help You answer any of the following items that:vod ❑QualifyingOFFer Nle!hod ❑ S3';'S O McCrod ' i have not aiready determined. Select only those that apply (lesr_plank if unsure): _ ._.-_......�_..—.-...- ....__...... _..._.._ .or Page Employer initial 0L �'gTASC tc.sa;l mau: 25E-63 0—ntrolleu Group: Please Indicate if you are a member of any of the followhrg: (required) • a Controlled Group of business entities under JR5 Section 414(b) 6r (c); ' P Q 4 ❑ Vas »it ye:,[er low' • an affiliated service group under IRS Section 414(m); Sir an arrangement described under IRS Seddon 414(0), , Government Entity Are /ou are a Government Entity that has reportable employees under l more than one EIN number"? Otto O Yes» If Yes,ldw' •If you answered YES to either question above, please complete the information in the section below far each meinmity within the Aggregated ALE, placing the entity with the most employees on top descending down to the entity with the fewest ees. A Plan Appilcation will need to be submitted separately for each entity. Entity's Legal Name Entity's EIN.Number. If there ere morethan 15 amides to report, please provide the remainder on an additional document. I ) ONLY: TASCACA- Special Instructions: ❑ ERISA Compliance Services • Set-up Fee (d PRICING + Annual Admin NOTEolpa wln10?1.n Mefrs[q(the month lit, nhth opplfcadon is retaived. (NFO: Based on num AdditfonalServices (addrtlar_ioleesapp!/J: _. Cl Medicare Part D Notices ❑ PPACA Notices` O Form 55OG Late Filing (x of a no."."J( ee(,Vb Minimum due now )( ) er of,lmployees _F_ ears be filed!__) O Additlonal BeneftPlans(9+) Cl Professional Services (billed hourly) O Wrap Documents• Ind. vldu I/Sepslate Affiliated Employer 0 Carrier CertiFlcates of Coverage attached to Plan Document/SPD ri,, key avtamednLy renew uanuopy $nAyselecti addition! Wrap Documents are needed beyond Included Mega -wrap Decumenr J The following benefits are subject,to ERISA requirements. Please complete each column as R relates to all benefits. "eretl by the Employer. IMPORTAN-f Not Your Plan Document/Summary Plan Description (SPD) will be prepared based on youranswers each question so please be t sure to answer these questions accurately and in agreement with the insurance certificates or summaries for these aneR#s.7hose Insurance jcerVicates and suimmaries will be Incorporated by reference in your Plan Document/5PD and to effect comprise an mporTnt part oiyour Plan j Document/SPD. Refer to KEVbelpwfor each column; I Column A: Applicable health & welfare benefits subject to ERISA- Indicate by completing all columns B -G fort neflt.9loHered by Employer. t For each applicable benefit offered, enter the Month and Date for the ACTUAL Contract Year of thePciirywith each abler. Column B: Ex.raple.- Health— Contract Yearis:anuary 1, renews every January 1 I Column C: 's fine Contract for this benefit issued ht the group name or Individual? Enter "G" for Group, or'9' to;]{individual. i Column D: For applicabla banerlts offered. are employees allowed to pre -baa Their contributions under your Set an li5 Plan? Enter "Y° for yes. or'N"for no. eve Employerinitht G� 9IVASi TC -3323-010117 . I 25E-64 — (A) �~ le) a ,Icl--_ ----(off ___..... Vic) - Coetrad aeenteontrad Pro. Tax Insuran¢ Cauleror Ise i �...�._ (G) 11 nelit 'Total a offevered Year writtento Gmup eeneM Service Provider Name Self-Insu ed ISl), jar; Part pants (moldd/yr1(GloriniliAdualsl9 flR9 FVIlydn ureJ l`) 1 ram a�adlM oepmdenu) Heath Dental ------- , ._De_ �_ __. .z .__•_ _. .__._ Vision ' Life I___ I i AD&0 STD LTD..._.._._._ _....._ _. , Voluntary/ Supplemental We or Aa&n P/ellrtess _ _ I _Employee Assistance Program EAP)_- • Stop Loss Insurance _._ _ . - Vol Othet ERISA Plans` J 'Olney EalSAPlens:chzdkWthy:urroeipllnna ada6arto determ/na¢these plans are Emp/oyersprvisored?tans s59CT to EO: Exa ples initude Prepaid legal Serace; Srho/ars$p Ponds, 0ay{are (enteri yacdtion 8enejiK,ApyrznUceship aratherTmfning 8enefits,Noiiday/Sevuance Benefits, and Np�sing Assistart¢Benefits. GROUP HEALTH PLAN INFORMATION Is Entity part of.' a Controlled Group of Corporations under Code Section 41416); ❑ No ' - a Group of ausiresses/Trades tinder common control ander Code Section 414(c) or ❑ Yes (see next question) ' - an Affiliated Serile sGraupunder Code Sectton414(m) 'CI -iSeporo[ean Acatfolnsarerequired. If YES, are benefits/Premiums /premiums paid from source? .O Yes 4 entiries n aybelinder oneAppiicaffon. r Under PPACA, current Group Health Pian is considered (sclect one): ❑ Grandfathered (GF) ❑ Nan- randfatfiered (N_ GF) Indicate if both items apply below: 1. you are considered an Applicable Large Employer (ALE) under the Employer Shared Responsibility provision of th ( Affordable Care Act (ACT), and; 2. You currently track employee hours to determine if any variable hour, Part-time, or seasonal employees' are "full O Yes C] No t time" Employees for purpaias of health plan eliglblllty _ .. Prescription Drug Plans Offered: O Creditable _ Non�Cmditable ❑ Roth Medicare Part D Coverage: 0 No 0 Yes r11llN ONLY: TASC ERISA • Special Instructions: i ❑PCORICompliance Services (with TASC ERISA -free) PRICING'No Set -Up Fe INFO: ' Annual Admii O PCORI Compliance Services (with out TASC ERISA) _ . Based on nun Fee (qua aw) beroFemployees (1)REQUESTFORINFORMATION 1 select all that apply to your current benefits and status: j O (A) Health Reimbursement Account (HRA) Cl (a) TASC HRA Client 0 (C) TASC Non -Excepted (Health) Flexible Spending'Accourt (NEFSA) Client 0 (0) Self -Insured Health Plan 0 1E)TASC H RA self -Administration Client /TASC Self -Administration NEFSA Client if you checked ONLY boxes A and B and/or C, you tan skip Part 2 below. :ail, Lo Employer InitialIip7aJ0 ro-aats-ran:v Il VV 25E-65 -'» (2) PLAN PARTICIPANT COUNT- I En_terthe following Participant counts (see instructions below on how to court Participants): f + 1st day of the 1st month ofyour Plan Year• Participant . ls[dayofthe 4thmonth,ofyouePlan Year: count as pf: 1st day of the 7th month of your Plan Year 1st day of the 10th month of your PlanYear: INSTRUCTIONS for Participant Count (based on answers InPart1 above): 1 -BoxA ONLY.participant Counts should equal the total number of HRAor NEFSA Plan Participants' ant le firsday of each quarter Box A and E ONLY, or during the Plan Year. Boz C and E ONLY ,. ... Participant counts should equal the total. number ofsalf-insured llezlth Plan Pa Ucipants .. on thy first day oFeach BOTH Box A and D, or quarter during the Plan Year. ` BOTH Box Cand D Ccunteach Health. Plan Participant with self -only coverage and thenadd to that the nuri 1 er of Participants withother thanselfanlycoveragemuldplied by235(the same Plan yearlsonimed%or both yovrHLia self -f ured Healthp!an), Participantcounts should equal thetotainum bee of selflnsurad Health Plan Partcipants antb, Rrstday of each quarterduring the Plan Year: Box DONCY Codnteach Health Plan Parttdpzntviith self;only coverage and thenadd to that the num or of Ifarticipants with other than self only coverage mulUplfed by 2:35 { . -1 . nclude all Coo RA Participants in yourcount but do not lndude'onyspouses brdependents that may, be coveredfundE r the Flan. ADMIN ONLY: TASC PCORI - Special Instructions: S ^t � T J��V'.�r �� O- C a 'LII, • ��£�� - (dug flow) fbenegts(odditicna_/feeg+) 1 PRICING Annual Admfn Fee O IRS Form 5500, Preparation INppf Based_ onnumb_nr +Late Fliing far Form SS007 ❑ No ❑ Yes if YES,. enter number rf late Rlings: ,VOTE-. Thi7efferlvis onyferangaing 5500 Plon&notformztnmers who are getting 5500prepjR anothereffeling. lfgE�1jlate/1 a0sn eded, p/eosezefect urNer �—� I WC ERISA offering ADMIN ONLY: TASC Form 5500 Prep - Special Instructions: j f + ` • �a. I .. �.: .. '�' 1 - ; r• -,; � w) (due7{ow) PRICING Set -Up Fee (ding P ❑Ma Testing RICIN • Annual Admin Fe n -Discrimination Basedonnumbe of employees ___ __.____• j PLANS TO BE TESTED_..-...--.._..,_. { Select Opal appfy,and indicate the start/enddatep for Plan Yearto betested: art Date: EndDate: ❑ Premium Only Plan (POP) /Sectlon 125 Plan): Eligibility Test, Contributions & Benefits Test - Availability & WIT zation,.Key Employee Concefltratfon Test i ❑ Flexible Spending Account (FSA) - D"ependeet Care (Section 129 Plan). Eligibility Test, �— Contributions&Bengt,Test, More than 5% 00ners Concentration Test 5595 Average eenefits Test �OFlexible Spending Account (FSA) -Medical: Eligibility Test, Benefits Test O Health Reimbursement Arrangement (HRA): Eligibility Test, Benefits -rest O Self -Insured Medical Pians: Eligibility Test, Benefits Test Group Term life Insurance: Eligibility Test, Benefits Test Plate: Group employees of 0Y entities must be tested if entity is a member ofo contralled group ofcorporations tra as, or bcsinesses under ` common control or an of dialed service. ADM IM ONLY: TASC Non-Discnm Testing -Special Instructions: age 11 Employer initial N'--, NIIY", raast:as 1" 25E-66 - No set-up ree I OgICING -"` - • Annual AdMIn F e- fiat rate (due now) (] TASC"HIPAA compliance Services �INR0: ee (billed autamedca Nm�: plan ud oa9� an the frsrc/rhe month in which oprccurron isreceried. " —___..— • Annual Renewal P ADMIN ONLY: TASCHIPAA- Special Instructions: - - - - ------ a Set -Up Fee(du tRomp, PRICING •Admin"" pe participant, per month ,INFO: Monthtyivion' none, Fee ❑ TASC Giveeack (Workplace Giving Administration) , Annual Renew l Fee 1 Wu ber of EIIgIble,Emplogees:; . ❑ �lonthl❑ other. ❑ Veekly p gl_ NeektI Semi-MonY i Payroll/Funding Cycle (select one): if Contributions In 12-md plan Year:rill dotes: Participant Eontri(iutiop Schedule: ccntdhution datesmoyarmoynot be_thzsamedata paYI 2`'Contributlon: Jam_ st Cnhtr)bution: _jJ_ "(663ed an Plan wndfn4sdl dole belpw/or 1"ConMbutloni Jam— � _-------- _ First Ycar Administration to begin: .Pint day oP __J— (01011) the month prior to tMssti . BENEFITOFPERIN�S ...-.. •— ^---^^^ Company Match: �— ❑ No ❑ Yes ! if yes, enter Maximum Match for each b Per Employee, Per Year; S Per Payroll: $ . ❑ No 17 Yes fjyes, enter Company Enrollment Bonus Enrollment Bonus: ❑Yes (company fvndraiserarfeatured employ This Seatondcures the method that your Plan will utilim to me a Payroll and payroll matchat is through AMW - sect,,, are In addition to the fess due under PART3 (Fes), The preferred method of payment Is through an Auto AM where TP Payment -via ACL. To start this process: (11 choose which ACH process you want beldw, (2) verily your Expected Da �rovid_eyour bank (1) O TASC ACH(default): TASC Initiates fundi ng payfnentvla Aai on the EOR. ❑ Client MYTASCFunding'. cientrnitiatesfundlngpaymentviaMyTASConorbeforethe-e0ft.Note.Underthis and Routing Numbers to post any unpaid funding amounts that are one (1) business additional annual fee w11I apply it ACH is not elected ($10.00 per paymll). (1) Expected Date of Receipt EDR is the date that TASC will pull in Auto ACH front your designated account ands parelclpanes account(s)- This may or may not be the same date as the participant's (EDR): payroll contribution schedule indicated above for each Payroll elde- (al Bank Information: ❑ Use same ACH Info from Part 4 of this Application Q Use differen Financial Institution Name: Bank Reuling Number (9 digits): Cheeping Accc ADIYIIN ONLY: TASC GiveBack - Special Instructions: page 11 Employer T:391a.0101V 25E-67 Of encs described in :his submission Of your fee lay pait the due date.Also, ply the payroll mriClbutlons to your syroll date. The EDR data Is the ACH. information as per belovr. State: int ti: ! I vII�TASC Pap,°L3 Emp!oy�r Initial ITC -3923410111 P� IPSC 25E-68 IWO i I I t i i I {( Pap,°L3 Emp!oy�r Initial ITC -3923410111 P� IPSC 25E-68 for Retiree Dental Benefits Billing SECTION I THIS AGREEMENT, entered into by and between Total Administrt Corporation ("TASC") and (the "Employer") City ofSanta Ana becomes effective signature on the Plan Application. The services apply to the Plan Year as note Application for retiree dental billing and continuing for successive years in whii Level Agreement exists. The terms of this Agreement shall be in effect indefinite automatically renewable. This Agreement is applicable to the Plan specified or Plan Application which is attached hereto as Exhibit A. 1. Services to be Provided Under this Agreement, TASC is considered to be the Administering provide timely administration and management of the appropriate Plan and ass as outline in the appropriate Product Administration manual/portfolio. 2. Emalover Responsibility Under this Agreemant, the Employer is considered the Plan Sponsor. P the Employer must forward to TASC all relevant information in order for functions to be performed in timely manner. This includes timely payment of invoices. Failure to provide inputs on a timely basis will result in delays and poss which will be the liability of the Employer. The Employers are responsible for Plan Participants on the services being provided. Employer is responsib', www.tascanGne.com;pro:idersllf[PAAr to execute and file the Business Associ provided by TASC. You will received infurmation regarding this within a le, EXHIBIT G I 25E-69 date of he Plan Service will be d in the will to this, ling, their visiting The Employer shall have the sole and final discretionary authority in respect administrative functions of the Plan. 3. Financial Responsibilities Responsibilityof Plan beneficiaries lies with the Plan Sponsor. TASC is managing the administration of those benefits. 4. Fees and Terms of Payment A. The Ernpioyer agrees to pay TASC for services provided under dais accordance with the appropriate Plan fee schedule, B. Invoices for services will occur 43 days prior to the service period (P and are due seven days from the invoice date. C. Fees may be subject to change without formal notice. Fees for cervi Services to be provided under this Agreement — or for additional servic necessary due to missing, incomplete or incorrect information — w. separately and will be disclosed to the Employer prior to incurring the are calculated on the number of employees in the Pian, includi employees, at the time of invoice. D. Employer is responsible For Administration Fees for Entire Plan. payment for administrative services may result in termination of Forwarding to collections for appropriate disposition. 5. Termination of Agreement A. Except as,'I result of nonpayment of (ees, this Agreement shall Conti it is tenminated by Employer or TASC with sixty days written no renewal date. 7 25E-70 and agent :went in :ar start) :side the become nvoiced e. Fees to remit or the until to Plan B. If services are terminated by Employer prior to the end of the existing Nan ear, the Employer is responsible for administration fees for the remainder of th it Plt n year. C. Non-payment of administration fees andto failure to remit funding on t tim.-ly basis may result in Plan termination. If services are terminated under this A>reerient, the Employer will be responsible for completing any outstanding services In 1'ckhtion. it is understood that termination of this Agreement also terminates the prov sion the TASC prototype Plan Document at which time the Plan will hencefort, be perceived as individually designed and the sole responsibility of the Employer. D. If terminated for failure to pay fees this Agreement may be termirtatee by TASC by providing the Employer with a 10 day written notice of said termir atior. Upon communication of Employer's intention to file Bankruptcy, TASC resE rves�the right to terminate services immediately. 6. Insurance TASC shall provide Plan $ponsor it certificate of insurance demonstrating pro -essional liability insurance coverage with a combined single limit of nut less than. 51,000 00 �cr claim with 52.000,000 in the aggregate prior to the start of work pursuant to this Ag eom¢nt. The following requirements apply to, the insurance to be provided by TASC pursuant thi section: A. TASC shall maintain all insurance required above in hill force and effeci for �le entire period covered by this Agreement. II B. Certificates of insurance shall be hnmished to the City upon exet;utioti of this Agreement and shall be approved by the City. C. Certificates and policies shall state that the policies shall nor be canceled or rduced in coverage or changed in any other material aspect without thirty (30) dny pri(Ir written 3 25E-71 notice to the City. ' 7. Confidentiality +(I I ff TASC receives from the City information which due to the nature ofsu ittt rmation is reasonably understood to be confidential and/or proprietary, TASC agrees that i shall not use or disclose such information except in the performance of this Agreement, and ruher Ila.;rees to exercise the same degree of care it uses to protect its own information of like imp rtan e, but in no event less than reasonable care. "Confidential Information" shall include ll r nP ublic information. Confidential information includes not only written informati n, llut also information transferred orally, visually, electronically, or by other means. Confidential information disclosed to either party by any subsidiary and/or agent of the other p rty i covered by this AgreernenL. The foregoing obligations of non-use and nondisclosure shad not apply to any information that (a) has beendisclosed in publicly available sources; (b) is, th ougl no fault of the TASC disclosed in a publicly available source; (c) is in.rightful possession of t e TASC without an obligation of confidentiality; (d) is required to be disclosed by opera[ on df law; or (e) is independently developed by the TASC without reference to information di. cloy d by the City. S. Lfmitatfons of Warranties and Liabilities A. Except as expressly set forth in this Agreement, TASC disclaims any ai d all express I warranties, warranties of fitness for a particular purpose and implied wanianties of merchantability. B. TASC will not be liable for any loss of business or profits, or any incidental, punitive, or similar damages, or, orher than asset furtli in this for claims of damages made by any third party tar any ;:cruse 4 25E-72 oCthe form of action, whether in contract or in tort, including negligdree, �ven if it has been advised ofthe possibility of such damages. C. Each party acknowledges that this limitation of liability reflects an i formed. voluntary allocation between the parties of the risks (known and unkn )wn) that may exist in connection with this Agreement. D. in no event will TASC's liability exceed the payments made by Empl yer to TASC within the previous six months for services provided under this A' emint. 'rillsshall be Employer's exclusive remedy. I E. No action, regardless of form, atising out of the services provid�d under this agreement, may be brought by Employer later than two years after t e dale the last services are provided under this Agreement. I 8. Execution and Delivery This Agreement may be executed and delivered (including by facsimile or� Portable Document Format (PDE) transmission) in one or more counterparts, all of vhicl� will be considered on and the same agreement and will become effective when one or mo a counterparts have been sighed by each of the parties and delivered to the other party. Any so h facsimile or I PDF documents and signatures shall have the same force and effect as manually-s'gned originals and shall be binding on Employer and TASC. 9. Discrimination TASC shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, age. national origin. ancestry, or disability, as defined and llprod iibited by applicable law, in the recruitment, selection, training, utilization, promotion, tenni iatioh or other I employment related activities. TASC affirms that it is an equal opportunity emp overland shall 25E-73 comply with all applicable federal, state and local laws and regulations. 11), Records TASC shill keep records and invoices in connection with the work to be p( this Agreement. TASC shall maintain complete and accurate records with resp( incurred under this Agreement and anyservices, expenditures, and disbursements City for a minimum period of three (3) years, or for any longer period required b3 date of final payment to TASC under this Agreement. All such records and im clearly identifiable: TASC shall allow a representative of the City to examine, at transcripts or copies of such records and any other documents created pursuant to P during regular business hours. TASC shall allow inspection of all work, dat proceedings, and activities related to this Agreement for a period of three (3) years of final payment to TASC under this Agreement. 11. Conflict of Interest Clause TASC covenants that it presently has no interests and shall not have indirect, which would conflict in;any mariner with performance of services s Agreement. 13. Governing Law This Agreement shall be governed under the laws of the State of 6 25E-74 ed under the costs ed to the From the shall be id make the date or this 13. Entire Agreement This Ageement represents the entire agreement of the parties and sL written or oral agreements. This Agreement shall not be altered or amended. ATTEST: MARIA HUIZAR Cleric of the Counci l AP,PR.OVED AS TO,FORNI: SOMA R. CARVALHO City Attorney n n By: c-owoc� Laura A. Rossini Senior Assistant City Attorney RECOMMENDED FOR APPROVAL: ED RAYA Executive Director of Personnel Services CITY OF SANTA ANA CYNTHIA J. KURTZ Interim City Manager TOTAL ADtVIENISTRA CORPORATION 7 25E-75 prior E SERVICES EXFIIBIT A PLA, APPLICATIO\ 25E-76 VAS Retiree Billing Application Follow duan is for fasr nd etiicienr urocessing of }'our Plan Application, Clicnrs musr complete all Secrimas. • P'Cisc print kgialy Far Lasino. C:nnracs-PASC fat 1-838-595-2261) fir wall the Plan Applicarion. Fix p;ur eompdettd Plan Aoplication't.ong ivirh }'aur ree ro 608.241.4584 or mail it co TASC, 2302 PO Bo: L4140. \4.:,I!,on WI 53704-8 L40. (1) EMPLOYER/ADMINISTRATOR f_ont.ar Nanm Cmnpmr.• Plame (Full legal none, ine!u.4ing y}i if zppl,ia'anitjI Canq,anyP ysirai:kd.1m;S;I LPO ?,.K) 2V�l"JC 7 ,} Alailiny:ld.L-ns:;—if from Ph}•sical .rJ.!rms 1 L ._ r Niro..andLax ID 2sofany' nr`hercomr.w'.h uivnaL'a+ucr,:iled conl}mltie::eLa( are par!dpating is the E -m1:1 A:h1( Ss _/l.e I�l)!'1�•� .t;ti :Da 1`_; C< — i.l.Y 'G(. �(,/ I 2hone Numu.:r_ /t 1 L�,—�`� %vp _Fax Number Sveisias Ped'.1 :D:_�� lt66 i-70 i N:\(C_tier5[C Cade (Found m: ms F.,. 55,;%u. 3dj, On you oar. 2.1miczsfin. W.. aeh:r bnsines:' Dyes (:-�Nu lf}'+u•nuu�'uer uLGupin;ets If Jou arc a arrear❑ianr dTASC: please nere which ser•:ice: 0 FIeaSJs:em (FSA) 0 HRA O COBRA 0 (2) PAYMENT T+c Mhlnntirf5['F+1'FY• InJ ::tYpllL r W.LY4n:}• LC ahrsmineJ is a fit• sched,le.tn1 invoke) m dm ruploye .. llw A. -:minis ?licarion, (South Uakna nsidu,a ad8 4rG saia <u.) dd.iiriurul cess may balnelia4. ro be decemJinrd by finzl renewal ;be O FNILA dnr a rine of an• I Scrricc I OneTtmcSecun-. I AdminutracoaFm I Other re I I i Retiree Billing S r ! �) �' v'(• L�l f�)J'i urinl.�zl v Zf\c-ter•:+• ! ' Fes an: scala:: m el:>rtge pendirt :evity nF P!mr Coe:nnrnu and infonngnon. and ltrclu:inaaon. f work invelvrh 0 Catck g Sigascnrc__ Cud a ___. .._._ _..... 0 %las[arCa-d :J Pisa 0 Ant.rian Exprri l 0 Hanle of Cardlmlder!, lame on Cud) E:cv. (3) E -PAY .ASCssr..ud.l:dmedu+d Farta4miasinn nfad,nin:t[rarun fcts is via E-Ih:: W0,:L•is'COice.l:\SC: convrnian:Ly deduus .n:ossnt. Simply onq,'e:e d:e Al •vnncn d::aic tut!:orpriuns nuac pr,.Wde char d:e Ri only bt•n,nif'inf:hc(lr:namrin rhe nutute. aPcCsidul d:::,ndsuri:aiinu. the Itnv::age in 1w aad:urtctnm+ up,",ws :<:12 -harm: d0ikC. taumr.:wsan:rion noticirs apnn Al:! -I Newark 1'aakiparts, dinanc:.l; L�- _ I-), If 71'.:�/ !I:r itmtru.,; ::v,::Fer Chr.:':w, Aemvn:.`:umLer _ is: r.. ren. .,_., rrurn :,,.....,.aJ:. T:.•nr.:ua. � :.... .: :r.r.Ii.-r•Sna arn.. �..:,v.cl i•; 25E-77 1 You; :twainz the anrwria;:rn.n e:tlillre:IWM ]di0el- (4) AUTHORIZATION 1 . ..... dpittdn,Mlllll It'd I'-.' d., W of ChO by 1_l L "C I HPAA Dwinc. .,U, em.pmy 12`5": rl, & �JIS A tia.) ,I I .... 44"If. llro%,ido� Agchr Nx,tt KeFiIm kj4 i\en'S L7 CA Q I (5) PLAN DESIGN Racave NiNlig Ph,, Opc: ... a (,Iicck oily one): i2z crillo4ri,., 0 Scandad Cuscom LvImm of Recired E,,,,pJoy,,e.% Pirr!gnm: 06) Mpving .. III, Bwt,fu Praviom TRA (C-InPtInY -Pr-e-CMITACI 113McAIId.DII.I.., Employcr Fur,.mr a Ps,el Wor1clicce (d,,.wrib.) A. A,,ailabl,, 8,uiefim Bondirs Avzailahlero *0=z m"ll"I "D rjc;,Cjl 0 W-10" 0 !jk (D Medi •am F.1 dble pjm,: %mfiu Admiui=rrd by Retiree Billing: C?,*,I,,dj,j 0,D,.%c,i 0 via �, Lo Q Lifit M44c,,:tim El gIA01.11. B. E.Mltn,e,Ic ":,,v Eligibk ikluchu,i Envoltmsr InfortnucicIl 111 be PruvPdcd w Retire: Billing: 0 eleararlic File 0 paper Form 0 Omrr,jaail a; Aa:;-r,BweJirE,,dDm,.-: Rerm., xledic.w 0.4bi, A9c65RemjIjcIrLgtre,: Oy" 0. No I Amicial SumMownt Chmigej op", Ell oll.mm scarr Due: L4�� Open Er.,,ffmI;,r Dirz: ait.ldic Chq- Dcadlim Dam —= =12-31 11 --7 --,— C. le,11cf, C.'"i,tr I-ifamucian (f&ll Lify !III 011ri..) ------------ Gxrri<r NI've C, 'Irm, I Imile Number Number li" Bg1lbilk?'t Billing To Rerk •3 E±S 55i/61 I. .s ('co-:, 3. M,: Amwh for III .,fors place.) Tr.:...... M,j,,j t. C.,,,: ,Z) EDI F:ie J Ci,mmr'X,,buir, 0 I7 PSI. C Gatoil G,-a,t..4 hifomicior, fl i*kl)cr lairtal 25E-78 tai; QAAPK,P pPl FIL 6_ WORK MAY PROCEED UNT L iHSIJRANCE EXPIRE, 1%-2011-258-02 CLERK OF COUNCII DTE EMPLOYER VANTAGECARE RETIREMENT -HEALTH- SAVINGS (RHS( PLAN ADOPTION AGREEMENT Plan Number: 8 03237 Select as applicable: ❑ Standalone RHS ❑ Integmred RHS El Amendment to Existing Plan ❑ New Plan (see NOTE bclmv) NOTE: (For existing employers only): Check here p if you want [CMA -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. 11:31 along with the adoption materials. Employer Retirement Health Savings Plan Name: 1. Employer Name: City of Santa Ana Scare: 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: 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 or Santa Arta Retiree Wetton aenofts Flan V. Eligible Groups, Participation and Participant Eligibility Requirements A. Eligible Groups The following group or groups of Employees are eligible to participate in the VanrageCare Retirement Health Savings Pian (check all applicable boxes): ❑ All Employees ❑ All Full -Time Employees ❑ Non -Union Employees ❑ Public Safety Employees — Police ❑ Public Safety Employees — Firefighters ❑ General Employees ❑ Collectively -Bargained Employees (Specify unic(s)) Police Management Association, Santa Ana Management Association, m Other (specify group(s)) Confiden0al Association of the City of Santa Ana 8 Full Time and Pan Time Civil Service Employees recognized by the Santa Ana City Employees, Chapter 1939/Service Employees international Union Loral 721 (SEIU) The Employee group(s) specified must correspond to a group(s) of the same designation that is defined in the statures, ordinances, rules, regulations, personnel manuals or other documents or provisions in effect in the state or locality of the Employer. B. Participation Alan canny Participation. tVI 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 underlyingwelfare benefit plan or funding tinder this Vantage Care Retirement Health Savings Plan is in whole or pan 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 tire 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 1. Nlinimum service: The minimum period of service required for participation is NIA minimum service is required). 2. Minimum age: The minimum age required for eligibility to participate is N/A age is required). > EXHIBIT H e 25E-79 (write N/A if no (write N/A IF no minimum VL Contribution Sources and Amounts A. Definition of Earnings The definition of Earnings will apply toall RHS Contribution Features that reference "Earnings", including Direct Employer Contributions (Section VI.B.I J and Mandatory Employee Compensation Contributions (Section VI.B.2.). Definition ofearnines: As defined by the MOU B. Direct Employer Contributions and Mandatory Contributions I. Direct Employer Contributions The Employer shall contribute on belialf of each Participant ❑ 96 of Earnings ❑ S each Plan Year ❑ A discretionary amount to be determined each Plan Year [71 Other (describe): See Attached 2. Mandatory Employee Compensation Contributions The Employer will make mandatory contributions of Employee compensation as follows: ® Reduction in Salary - % of Earnings or $ will be contributed For the Plan Year. ❑ Decreased Merit or Pay Plan Adjustment -All or a porion of the Employees' annual merit or pay plan adjustment will be conrribured 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 Contriburions Tic Employer will make mandator• contributions of accrued leave as follows (provide formula for determining Mandatory Employee Leave contributions): Z Accrued Sick Leave See Attached ® Accrued Vacation Leave See Attached m Other (specify type of leave) Accrued Leave See Attached An Employee shall nor have the righr to discontinue or vary the race of mandatory leave contributions. C. Limits on Tom( Contributions (check one box) The total contribution by the Employer on behalf of each Participant (including Direct Employer and Mandatory Employee Contributions) for cacti Plan liar shall not exceed the following limic(s) below. Limits on individual eoncribucion types are defined within the appropriate section above. 25E-80 JZ] There is no Plan -defined limit on the percentage or dollaramount of earnings that may be contributed. ❑ %of earnings` 'Definition of earnings: ❑ Same as Scction VI.A.. ❑ Other ❑ $ for the Plan year. See Section V.B. for a discussion of nondiseriminarion rules dear may apply to non-eollectivdy 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 ofScrvicc Vesting Completed Percentage oo _ -_g'o B. The account will become 1000,o 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 ❑ Otter 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 participants death (as outlined in Section XI), a Parricipanrs non -rested funds shall (check one box): ❑ Remain in the Trust to be reallocated among all remaining Employees partieiparing in the Plan as Direct Employer Contributions for the next and succeeding contribution cycle(s). 0 Remain in the Trust m be reallocated on an equal dollar basis among all Plan Participants. ❑ Remain in the Trust to be radlocated among all Plan Participants based upon Panicipant account balances. ❑ Revert to the Employer. 2E-81 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 SectionVll.B. ❑ Other {ZJ 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 redremenr 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 9 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 Benefirs eligible for reimbursement consist of. ® All Medical Expenses eligible under IRC Section 21Y 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' otter 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 VanmgeCare Retirement Health Savings Plait: ❑ Medical Insurance Premiums ❑ Medical Out-of-pocket Expenses' ❑ Medicare Part B Insurance Premiums ❑ Medicare Part D Insurance Premiums s, l 25E-82 ❑ Medicare Supplemental Insurance premiums ❑ Prescription Drug Laurance Premiums ❑ COBRA Insurance Premiums ❑ Dental Insurance Premiums ❑ Dental Out-of-pocket Expenses' ❑ Vision Insurance Premiums ❑ Vision Our-of-Pocker Expenses' ❑ Qualified Long -Term Care Insurance Premiums ❑ Non -Prescription medications allowed under IRS guidance' ❑ Other qualifying medical expenses (describe)' See Section VA. far a dirtunion ofnatdherindnation rulrs which pray apply to non -collectively bargained, re/f-inrnred Plans. XI. Benefits After the Death of the Participant In the event of 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 XILD.) oFche 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. 71n inrertnrent in the Dreyf n Car, Alanagmioo money nmrketf..rd it not inrured orguaraweed by the Federal Deporit Ln'raun Corporation many otberguvernmeut gency. Although the f urd reeky to prererre for vabre efyour invatnrearat 51.00 perrbare, it it parrible to lore money by inverting in thefund. Inverrorr should consider ibe inrertnrent objretiver, rirkr, rlragei, and erpenrer ofibe fund nrrefrd/y beforr inveitiug. You nnty visit nr at mtvrv.ieruam-org or call SOO.669-7400 to obtain a pm pectis t,nt rontainr tbii and other it formation about the fiord. Reid the prorpecna carefully before inverriug. If a Participant's account balance has nor 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 Sponse 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 VantageCam Retirement Health Savings Plan Participant status updates or personal information updates via electronic submission. This includes bur 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. 5E=83 C. Auignnsent rrbeucrits is not pet in Beoefirs will be paid only m the Participant, his/her Survivors, the Employer, c r an insurmce provider (as allowed by the elainu admbtisurnmr). Payments man third -party payee (e.g.. medical service provider) arc nor permiued will, Elie exception of reimbursement in the Employer or insurance provider (as ullowed by the claims adminisrratnd. D. An eligible dependent is (,d the Participants lawful spouse, (h) cite Participanri child tinder rhe age of 27, as dclincd by IRC Section, 152(0(1) and Internal Revenue Service Notice 2010-38, or (c) any other individual who is a person described in IRC Section 152(a). as clarified by Inrermal Revenue Service Notice 2004-T). E. The Employer will he responsible for withholding, reporting and remising any applicable taxes rnr prynscors which are deemed to be diseriminaccry under IRC Section 105(h), as outlined in Elle VSmageGw Retirement Flealth Savings Plan Employer Manual. XIII. Employer Acknowledgements A. The Employer hereby acknowledges it undcrsmnds char failure to properly rill our this Employer VancngeCam Reriremcnc Health Savings Plan Adoption Agreement may result in the loss of tax exemption of the Tmsr and/or loss of rax -deferred status for Employer contributions. B. 0 Check this box if you are including supporting documents that include plan provisions. EMPLOYE•RSIGNATURE d By. _ .. �� � Date: 1 '� Title, City 6 nage. Attest• Date: Tide. Clerk of the Council Accepted: VADITAGEPOfNTTRANSFER AGENTS, LLC APPROVED AS TO 17010,1 5>v�iy Laura A. Rossini eLsistanr eeretary, ICNIA-RC Senior Assistant City Attoriw.. M;RIA • 1 ZAR CLERK OF THE COUNCIL DEC D 8 2015 25E-84 City of Santa Ana RHS Plan #803237 Amended 1/1/2016 Eligible Group: Police Management Association (PMA) 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 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 1990 who separate from service on or after July 1, 2011 will contribute 100% of holiday leave payout and 1000 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.13.2. 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 ofterJuly 1, 2014 will contribute 100% of eligible sick leave payout 25E-85 A-2011-258-02 IL oVZ)VNANCE EXPIRES 1-15 EMPLOYER VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PLAN IH1 F1. ,,i ADOPTION AGREEMENT Plan Number: 3 03237 Select as applicable: ❑ Stvtdalonc RHS ❑ Integrated RHS 0 Amendment to Existing Plan ❑ New Plan (see NOTE below) NOTE: (For existing employers.only): Check here [2) if you want 1CMA-RC to use existing plan contact information for this new plan setup. Otherwise, if contact information has changed, please complete and return chi: Implementation. Data Form found on pg. II:31 along with the adoption materials. Employer Retirement Health Savings Plan Name: 1. Employer Name: City of Santa Ana State: CA 11. The Employer hereby attests that it is a unit of astate 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: Odlober 1, 2014 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 ofSanta Ana RettreeWellareBenefiitsPlan V. Eligible Groups, Participation and Participant Eligibility Requirements A. Eligible Groups The following group or groups of Employees are eligible to participate in the VamageCare Retirement.Healdh 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 ❑ Collectively -Bargained Employees (Specify unit(s)) Police Management Association, Fire Management Association, Other (specify gmup(s)) Collectively -Bargained Employees continued: Santa Ana Management Association & Confidential Association of the City of Santa Ana 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 du Employer. B. Participation klandatory Participation: All Employees in the covered group(s) are required m participate in the Plan and shall receive contributions pursuant to Section VI. If the F.mploycr's underlying welfare benefirplan br.,funding.under Ellis VaittageCare Retirement Health Savings Plari4s iti ; i- whole or pa,'rt a non -collectively bargained self insured pla vthe nondiscrimination requirements of Internal Revenue (IRC) Section 105(h) hilt apply. These: rules may impose taxation on the benefiii;rec&t ed by highly compensated mdtytduals if the Plandncnmmates'infavor ofhighly compensated individuals in terms ofeligihility or benefits fhhc Employer should discuss these rides with appropriate counsel. C. Participant Eligibility Requirements I. Minimum service: -Ilse minimum period of service required for participation is N/A (write NIA if no minimum service isrequired). 2. Minimum age: -lie minimum age required fur eligibility to participate is NIA (write NIA if no minimum age is required).---- VI. Contribution Sources and Amounts A. Definition of Earnings -Ihe definition of Earnings will apply to all RHS Contribution Pcamresdtat reference "Earnings", including Direct Employer Contributions (Section V I.B.I.) 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 Plait Year ❑ A discretionary amount to be determined each Plan Year ❑ Other (describe): See Attached 2. Mandatory Employee Compensation Contributions The Employer will make mandatory contributions of Employee compensation as follows: ® Reduction in Salary sa"t"arJod % of Earnings or $ will be contributed for the Plan Year. ❑ Decreased Merit oi• 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 An Employee shall Lint have the right to discontinue or vary the rate or mandatory leave contributions. C, Limits on Total Contributions (check one box) -Ihe tot -,d contribution by the Employer on behalf of each Participant (including Direct Employer and Mandatory Employee Contributions) for each Plan Year shall nor exceed the following limir(s) below. Limits on individual contribution types are defined within the appropriate section above. f' � ; t r.w � � t' •��� �7'. .1.. 1t � �� iii .a.. .. a.. ..c ® There is no Plan -defined limit on die percenragc or dollar amount of earnings that may be contributed. ❑ % of earnings* *Definition of earnings: ❑ Same as Section VIA. ❑ Other ❑ S for the Plan year. See Section V.B, for a discussion of nondiscrimination rules that may apply to non-eollectively bargaitudself-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 oudined in Section VI.FI.I.: Years of Service Vesting Completed Percentage % 0% 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 sctvice bra Participant prior to a rehire of the Pnrticipant by the Employer shall not count toward the vesting schedule outlined in Aabove. VIII. Forfeiture Provisions Upon separation from theservice of the Employer prior to attainment of benefit eligibility (as outlined in Section IX), or upon reversion to the Trust of a Participants account assets remaining upon the participants death (as outlined in Section XI), a Participants 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 tine next and succeeding contribution cycle(s). ❑ Rcmain 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. v _..,2SE=$$ .. _. . 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 Seaimi VILB. ❑ Other {Q At separation from service with dee following restrictions ® No restrictions ❑ Other B. Termination prior to general benefit eligibility: ht case where the general benefit eligibility as outlined in Section IX.A includes a retiremem.component, n Participant who separates from service of tlic 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 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 oL ® All Mcdical Expenses eligible under IRC Scction-213' other than (i) direct long-term care expenses, and (ii) expenses for medicines or drugs which are not prescribed drugs (other than insulin). ❑ -Ihc following Medical Expenses eligible under IRC Scction 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 l-lealrh Savings I'lan: ❑ Medical Insurance Premiums ❑ Medical Our -of -Pocket Expenses' ❑ Medicare Part B Insurance Premiums ❑ Yledicire Part D Insurance Premiums r ❑ 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 medicationsallowed under IRS guidance' ❑ Other qualifying medical expenses (describe)' `Sec Section V.A. for a-ditu,rfat ofnondiseinbnatio,.rtdei which may apply m ton -collectively bargained, self-insured Plat,: 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 XILD) of the deceased Participant are immediately eligible to maintain the account and utilize it m fund eligible medical benefits specified inSection X above. Upon notification of a Participant's death, the participant's account balance will be transferred into Dreyfus Cash Managcmentfund' (or another fund selected by the Employer). The account balance may be reallocated by the surviving spouse or dependents. 'In invemnrnt in the Dreyfi, Cath Management nnuney market fond h not injured a, guaranteed by the Federal DelowitInsuranre Corporation or any othrrgooenunent agenry. Although the fund seek; to preserve the Oahu of your investment at$1.00 per share, it i; possible to lou money by investing in tfie find luveitori sbomld rontider the innei,nert abjectivet, risks, charges, and eapeuer ofthefnnd rarrfidly before inveitirrg. You may visit us at uwmicmarrtorg or call 800-669-7400 to obtain a prarpecnu that nnntain; thin and orber information about the frond. Read the prosperna carefrdly, before invetbrg. 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 it 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 I. The Employer will submit all VantageCare Retirement Health Savings Plan contribution data via electronic submission. 2. The Employer will submit all VanragcCare Retirement Health Savings Plan Participant status updates or personal information updates via electronic submission. This includes but is nor limited to rermination 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 benefirs 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) arc not permitted with the exception of reimbursement to the Employer or insurance provider (as allowed by the claims administrator). D. An eligible dependent is (a) the Participant's lawful spouse, (b) the Panicipanc s child under the age of 27, as defined by IRC Section 152(f)(1) and Internal Revenue Service Notice 2010.38, or (c) any other individual who is a person described in IRC Seecion 152(x), as clarified by Internal Revenue Service Notice 2004-79. E. The Employer will be responsible for withholding, reporting and remitting any applicable (axes for payments which arc 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 Rciircment 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. Be ® Cheek this box if you arc including supporting documents that include plan provisions. EMPLOYEFSIG PLE L / By:, O,/) /- i/iy�tY/ Tyler City Manager r ^ Attest; Clerk of the Council Acccptcd: VANTAGEPOINT TR/uNSFER AGENTS, LLC t z Assistant gecrctary, ICvul-RC Date: Date: 25E-91 A,PT , "0 AST FO RIM / Joseph Straka Assistant City Attorney A-201 EMPLOYER VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PLAN ADOPTION AGREEMENT Plan Number. 8 03550 Select as applicable. ❑ Standalone RHS ❑ Iniegrand RHS [D Amendment m Existing Plan ❑ New Plan (.see NOTE below) NOTE: (For existing employers only): Check here © ifyou s¢u¢ ICNIA-RC to use esisring 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. 11:31 along with die adoption materials. Employer Retirement Health Savings Plan Name: 1. Employer Name: City of Santa Ana State: California Il. The Employer hereby attests that it is a unit oFa state or loaf government or an agency or instrumentalityof one or more units ofa state or local government. III. Effective Date ofthe Plans 061012015 N. The Employer intends to utilize the Trust to fund only welfare benefits pursuant to the following welfare benefit plan(s) established by the Employer: Ceyor Sam.Ana Reseaweiremae,cM4P6 V. Eligible Groups, Participation and Participant Eligibility Requirements A. Eligible Groups The following group or groups of Employeks are eligible to participate in die VantageCare Retirement Health Savings Plan (check all applicable boxes): ❑ All Employees ❑ All Full -Time Employees ❑ Non -Union Employees ❑ Public Safcty Employees — Police ❑ Public Safety Employees — Firefighters ❑ General Employees ❑ Collectively-Bargai=1 Employees (Specify unit(s)) 0 Other (spccifv group(s)) City Manager Tyre Employee group(s) specified mttsc correspond m 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 clue irate or locality of the Employer. B. Participation Alandatoty Partieipatiom NI Employees in die covered group(s) are required to participare in rite Plan and shall receive contributions pursuant to Section VI. If elm Employes underlyingwelfare benefit plan or Funding under this V.tnrageCare Retirement Hcsleh Savings Plan is in whole or pan a non -collectively bargained, self-insured plan, the mndiscriminarion requirements of Internal Revenue Code (IRC) Section 105(h) will apply. These rules mry impose taxation on the benefits received by highiymmpensared individuals if the Plan diserindjura in favor of highly coinpemarcd individuals in terms oFeligibility or henefin. The Employer should discuss these rtes with appropriate counsel. C. Participant Eligibility Requirements 1. Minimttnt service: The minimum period oFservice required for participation is NIA (write NIA if no minimum service is required). ?. Nliuinmm age: The miriinmm Age required for c[i 6iili[y to participate is (scalae \4:1 Wan minimum age is required). , t . 25E-92 N VI. Contribution Sources and Amounts A. Definition of Earnings 'Ilse definition of Earnings will apply to all RHS Contribution Features that reference "Earnings including Direct Employer Contributions (Section VLB.1.) and Mandatory Employee Compensation Contributions (Section VLB.2.). Definition of earnings: As defined by the City Manager Employment Agreement. B. Direct Employer Contributions and Mandatory Contributions 1. Direct Employer Contributions Tlse E• nsployer shall contribute on behalf of cads Participant ❑ %oFEarnings ❑ S each Plan Year U A discretionary amount to be determined each Plan Year Other (describe): A one-time contribution as a conversion from the existing Medical Retirement Subsidv Plan. 2. Mandatory Employee Compensation Contributions The Employer will make mandatory contributions of Employee compensation as follows: ® Reduction in Salary - 1.95 % 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 rare 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 100% of sick leave cash out ❑ Accrued Vacation Leave ❑ Other (specify type of leave) Accrued Leave An Employee shall nor 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 limits) below. Limits on individual contribution types are defined within the appropriate section above. 25E-93 ® There is no Plan -defined limit on the percentage or dollaramounr of earnings chat may be contributed. ❑ % of eamings' 'Definition ofearnings: ❑ Same as Section VLA.. ❑ Other ❑ $ For the Plan year. See Section V.B. for a discussion of nondiscrimination rules chat may apply to non-colluctively bargained self insured Plan,. VI I. 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 m Direcr Employer Contributions as outlined in Section VLB. L: Years of Service Vesting Completed Percentage o/O _% _aa % °h _% _/a B. The account will become 100% vested upon cite death, disability, retirement', or attainment of benefit eligibility (as outlined in Section IX) by a Participant. 'Definition of rerin:menc includes a separation from service component and is further defined by (check one): ® The primary recirentcnt plan of die Employer ❑ Sepa scion from service ❑ Othcr 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 sepacation from rhe service of rhe Employer prior to attainment of benefit eligibility (as outlined in Section (X), or upon reversion to the Trust of a Parricipues account assets remaining upon die participant's dealt (as outlined ill Section XI), a Participant's non-veued funds shalt (check one box): ❑ Remain in the Trust to be reallocated among all renuining Employees participating in rhe Plan as Direct Employer Contributions for cite next and succeeding enncriburian cycie(s). [✓J Remain in rite Trust m be reallocated on an equal dollar basis among all Plan Participants. ❑ Remain in the Trust to be reallocated aniong:dl Plan Participants based upon Parricipattraceaunt balances. ❑ Revert to the Employer. 25E-94 I IX. Eligibility Requirements to Receive Medical Benefit Payments From the VantageCare Retirement Heahh Savings Plan A. A Participant is eligible to receive benefits: ❑ At retirement only (also complete Scc ion B.) Definition of retirement: ❑ Sameas Section Vll.B. j ❑ Other m Ar sepamtion From scivicc with rhe following restrictions ® No restrictions ❑ Other i B. Termination prior to general benefit eligibility; In ease where the general benefit eligibilky 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: I m Immetliamly upon sepamtion fmm service ❑ Other C. A Participant that becomes totally and permanently disabled ❑ as defined by the Social Security Administration as defined by the Employer's primary retirement plan i ❑ 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 shill become payable as outlined in Section XI. X. Permissible Medical Benefit Payments Benefits eligible for reimbursement consist of: ® tMI Medical Expenses eligible under IRC Section 213' otter than (i) direct longterm 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' ocher than (i) direct longterm care expemes, and (ii) expenses For medicines or drugs which are nor prescribed drugs (other than insulin). Select only die expenses you wish to 4 cover under the VantageCare Retirement Health Savings Plan: j ❑ 4lediml Insurance Premiums ❑ Mediml Our -of -Pucker Expenses' I ❑ \dedictre Part B Insurance Premiums ❑ Medicare Parr D Insurance Premiums I 25E-95 ❑ Alediasre Supplemental Insurance Premiums ❑ Prescription Drug Insurance Premiums ❑ .COBRA Insurance Premiums ❑ Dental Insurance Premiums ❑ Denral Our -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 Vel. fora drrcnnion ofoandirrrinunatiwr rider Urdu) rraj appy to non -collectively bargained, n!f_Grrored plan. XI. Benefits After the Death of the Participant In the event of a Participant's death, the followingshill apply: A. Surviving Spouse anchor Surviving Dependents The surviving spouse and/or surviving eligible dependents (as defined in Section :GILD] of the deceased Participant ate Immediately eligible to maintain the account and utilize it to find eligible medical benefit specified in Section X above. Upon nodficatfon of a Participant's death, the Participant's account balance will be transferred into Dreyfus Cash sbfanagemenr fund' (or another fund selected by the Employer). The account balance may he reallocated by the survivingspouse or dependents. A,, invatnnnt in the Drv;fiu Cirri; rslanagmrnr none;, inarkerfurid ii nor inrnnd ogrramnital byte Feder I Deparir Innrrmre Corporation oraty other wcenrmeor agency. Although de fiord ieekr to prerace the cadre afyour investment at SL 00 purbare, it it terrible N Ione money by inverting in rbefund Ir, rmtand... Id n nrido rhe inunrnma objectives, risks, Anger, and espenitr oftbefrad rarrfuly before invaiiiig. Ynu unq Quit m at wwty.innartmg arra!/ R00-669-yt00 ro obn+in n proipnnu di tr ronrainr 16ir.nrAorbrr hifunnatian nbu:a rbejuna. Raid the proiperrrn rorefidly before investing. If a Participants account balance has not been fully utilized upon the death of the eligible spuust, theaccount balance may coutinuc to be utilized to pay benefits of eligible dependents. Upon dse death oral[ eligible dcpcndcnts, the accounr will revert to the Plan to be applied as specified in Section Vlll. B. No Surviving Spouse or Surviving Dependents If there are no living spouse or dependents at the time of death of tine Participant, rite account will revert to the Plan to be applied as specified in Section V I 11. XII. The Plan will operate according to the following provisionst A. Employer Responsibilities L "Bic Employer will submit all VanngeCare Retirement Flealth Savings Plan contribution data via electronic submission. The Employer will submit all VantageCare Retirement Healtls Savings Plan Participant status updates or personal information updates via electronic submission. Ibis includes but is not limited to termination notifintion and benefit eligibility notification. B. Participant account administration and asset-based fees will be paid risrough the redemption of Participant account shares, unless agreed upon otherwise in rile Administrative Services Agreamem. 25E-96 C. Assignment of benefits is not permitted. Benefits will be paid only In the Ilarricipanr, Itisther Survivors, the Employer, or an insurance provider (as allowed by the claims administrator). payments to an third -parry payee (e.g., medical service provider) are not permitted with cite exception of reimbursement to the Employer or insurance provider (as allowed by the claims administrator). D. An eligible dependent is (a) cite Participant's lawful spouse, (b) the Participants child under the age of 27, as definctl by IRC Section 152(0(1) and Internal Revenue Service Notice 2010-38, or (c) 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 am rimmed to be diseriminarory under IRC Section 105(h), as ourlined in cite VancageCare Retirement Health Savings flan Employer Manual. XIII. Employer Acknowledgements A. The Employer hereby acknowledges it understands chat failure to properly fill out this Employer VanageCare Retirement Health Savings Plan Adoption Agreement may result in the loss of ax excnaptian of the Trust and/or loss of tax-deferred status for Employer contributions. B. ❑ Check this box if you are including supporting documents that include plan provisions. EMPLOYER SIGNATURE By:_(y7-l�tnG� 1" l `-� Title, Executive Director, Personnel Services Attest;_"/ / \ 6'iMlL 2- J IV[' f Title: Clerk of the Council Accepted: VA. iTAGEPOINT TRANSFER AGENTS, LLC v..�a� Assistant, ecrerarv, ICNLI RC PPR 0 FORM Jose San o enior Assistant City Attorney Date: �5/aO/ � s Date: 5- Ze2�/r�r%/� CLF.S(K OF E COUNCIL 25E-97 SUGGESTED AFFIRMATIVE STATEMENT FOR ADOPTION OF THE VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PLAN Plan Number: 8 03551 Namc oFlimploycr. City of Santa Ana Affirmative Statement of the above-named Employer (the "Employer"): WHEREAS, the Employer has employees rendering valuable services; and snuc, California WHEREAS, the establishment of a retiree health savings plan serves the interests oFthc Employer by enabling it to provide reasonable security regarding such employees' health needs during retirement. by providing increased flexibility in its personnel management system, and by assisting in the attraction and retention of competent personnel; and WHEREAS, the Employer has determined char the establishment of the retiree health savings plan (the "Plan") serves the above objectives; NOW TH EREFORE, as a duly authorized agent of the Employer, I hereby: ESTABLISH the Employer's Plan in the form of the ICMA Retirement Corporation's VantageCarc Retirement Health Savings program; and SPECIFY than the assets of the Plan shall be held in trust, wirh the following entity or individual serving as trustee (Selecr one): 0 the Employer ❑ the following position within the Employer. ❑ the following group or committee within the Employer. ❑ the following rhird-parry trusree: f iwn vtv meind";duat 3vMnp nuaml lie"t;VwPm cw,miun xdvps uw,R7 Gnrnmn¢ar,M,d.ya,m niuue7 for the exclusive benefit of the Plan participants and their survivors, and die assets of the plan shall not be diverted to any other purpose prior to the satisfaction oral) liabilities of the Plan. The Employer has executed the Declaration of vast oFthe City of Santa Ana Integral Part Trust in the form oF. (Selecr one) IZI The model trust made available by the ICMA Retirement Corporation ❑ The trust provided by the Employer (executed copy attached hereto). SPECIFYrharthe Personnel Services/Employee Benefits Department shall be the coordinator and contact for the Plan and shall receive neecssery reports, notices, etc DATE: FEB 0 5 2015 ATTEST i�GL�^RlLI�S�r� ARIA D HUIZAR /J CLERK OF THE CO CIL City Manager Tide of Designated Agent Signature 25E-98 g5 EMPLOYER VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS( PLAN ADOPTION AGREEMENT Plan Number: 8 03551 Sclect as appliablr. ❑ Srandalone RHS ❑ lntegmted RHS ❑ Amendment to Existing Plan [Z] Nesv Plan (sec NOTE below) NOTE: (For existing employers only): Check here Q if you want ICViA-RC to use existing plan contact information for this nesv plan setup. Otherwise, if contact information has changed, please complete and return the Implementation Data Form found on pg. 11.31 along with the adoption materials. Employer Retirement Health Savings Plan Name. I. Employer Name: Cityof Santa Ana Stat, California 11. The Employer herebyattests 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: 01/2012015 IV. The Employer intends to utilize the Trust to fund only welfare benefits pursuant to the followingwelfare benefit Plan(s) established by the Employer. cyGsania nna metaee wesare ea+efiu roan V. Eligible Groups, Participation and Participant Eligibility Requirements A. Eligible Groups Tlae following group or groups of Employees arc eligible to participate in she VantagcCarc Retirement Health Savings Plan (check all applicable boxes): ❑ All Employees ❑ All Full --•lime Employees ❑ Non -Union Employees ❑ Public Safety Employees— Police ❑ Public Safety Employees— Firefighters ❑ General Employees ❑ Collectively-Ilargained Employees (Specify unit(s)) ® Other (specify group(s)) Clerk of the Council, Chief of Police and Unrepresented Executive Management 'lhe Employee group(s) specified must correspond to a gmup(s) of the same designation that is defined in the starutes, ordinances, rules, reGulations, personnel manuals or other documents or provisions in effect in the stare or locality of the Employer. B. Participation Alandatoty Participation: All Employees in the covered group(s) arc required to participate in the Plan and shall receive contributions pursuant to Section VI. If the Employers underlying welfare benclic plan at funding under this \':uuageCl re Re[irca nt Hcalth Savings Plan is in whale or Pasta non-collcetively bargained. self•incured plan, the nondiscrimination requirements of Internal Revenue Code (IRC) Swinn 10500 [rill apply. Hese rules may impose taxation on the benefits received by highly compennred individuals ifthe PLm diseriminans in !carat of highly cmnprns;med individuals iu terms oFcligibilicyor benefi�s.'[be Emplpyct zbonld discuss [hese rules with appropriate counsel. C. Participant Eligibility Requirements I. Minimum service The minimum period of service required for participarion is N/A (write NIA if no minimum service is required). 2. Minimum age: •Ilne minimum age required for eligibility to participate is NIA (avrire NA if no minimum age is required). �. 25E-99 VL Contribution Sources and Amounts A. Definition of Earnings The definition of L'arnings will apply to all RHS Contribution Peatunns 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 Resolution 2015-01. B. Direct Employer Contributions and Mandatory Contributions 1. Dircct Employer Comributions ILe Entploycr shall contribute on bebalr of each participant ❑ %ofEernings Cl S each Plan Year ❑ A discretionary amount to be determined each Plan Year El Other (describe): A one-time contribution as a conversion from the existing Medical Retirement Subsidy Plan. 2. Mandatory Employte Compensation Contributions The Employer will make mandatory contributions of Employee compensation as follows: ® Reduction in Salary - 125 % of Earnings or 5 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 rare 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): m Accrued Sick Leave 100% of sick leave cash out ❑ Accrued Vacation Leave 0 Other (specify type of leave) Accrued Must Use Leave Unused Lontimityand RegularVaralion designated as Must Use leave as of 0ecember31st each year. The maximum allowable Must Use time contributed cannot exceed the allowable cash out applicable for that Fiscal Yearandlor Calendar Year. An Employee shall not have the right to discontinue or vary the rare of mandatory leave contributions. C. Limits on Total Contributions (check one box) ' lie total contribution by the Employer on behalf of each Participant (including Direct Employer and Mandatory Employee Contributions) for each Plan Year shall nor exceed the following limits) below. Limits on individual contribution types arc defined within due appropriate section above. 25E-100 ® Tlicre is no Plan -defined limit on the percentage or dollar amount of earnings that may be contributed. ❑ %ofearnings' 'Dclinitionofearnings: ❑ Same as Section VLA.. ❑ Other ❑ $ for the Plan year. See Section V.B. fora discussion of nondiscrimination rules that may apply to roti-collcerivcly ba gained self-insured Plum. VII. Vesting for Direct Employer Contributions A. Vesting Schedule (check one box) ® Tlic 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 ofScrvicc Vesting Completed Percentage ob n� ob _oro °/u B. The account will become 100%vested upon the death, disability, retirement*, or attainment of benefit eligibility (as outlined in Section IN by a Participant. 'Definition of retirement includes a separation from service eomponeut and is further defined by (check one): ❑ The primary retirement plan of rhe Employer ❑ Separarion from service ❑ Other C. Any period of service by a Participant prior to a rehire of the Participant by the Employer shall trot 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 Participant's account assets remaining upon the participant's death (as outlined in Section XI), a Participant's non -rested funds shall (check one box): ❑ Remain in the T ru.sr to be reallocated among all remaining Employees participating in the Plan as Direct Employer Contributions for the next and succeeding eon[ributiou evcle(a). 1n Remain in the Trusr to be reallocated on an equal dollar basis among all Plan Participants. ❑ Remain in the Irusr to be reallocated among all Plan Participants based upon Parricipam account balances. ❑ Revert to the Eniplover. ,t 25E-101 EX. 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: ❑ Sameas Section Vll.B. ❑ Other ❑ At separation from service with the following restrictions ® NO restrictions ❑ Other B. Termination prior to general benefit eligibility: In case whcrc rhe gencml bencfir eligibility a% onrlined in Section IKA 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 SecurityAdministration ® u defined by the Employer's primary retircmcnt 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 mcdicincq or drugs which are not prescribed drugs (other than insulin). ❑ 'Ihe following Nledical Expenses eligible under IRC Section 213` other than (I) direct long -terra care expenses, and (ii) expenses for medicines or drugs which arc not prescribed drugs (other than insulin). Select only the expenses you wish to cover under the V;mtageCam Retirement Health Savings Plan: ❑ Medical Insurance: Premiums ❑ Medical Oto -of -Pocket Expenses, ❑ Medicare Part B Insurance Premiums ❑ Medicare Part D Insurance Premiums al 25E-102 ❑ Medimm Supplemental Insurance Premiums ❑ Prescription Drug Insurance Premiums ❑ COBRA Insurance Premiums ❑ Dental Insurance Premiums ❑ Dental Out -of -Pocket Expenses' ❑ %ision Insurance Premiums ❑ Vision Out -of -Pocket Expenses' ❑ Qualified LonS'term Care Insurance Premiums ❑ Non -Prescription medications allowed under IRS guidance' ❑ Other qualifi-ing medical ctpettses (describe)' See Src ion V.A. for a.dimrrdon of nonditrrintination rola which may apply to non-colleainely bargainer!, self-insured Placer. XI. Benefits After the Death of the Participant In the event of a Participant's death, the fallo%ing shall apply: A. Surviving Spouse and/or Surviving Dependents 71te surviving spouse and/orsuniving eligible dcpendena (as defined in Section XILD.) of dm deec.acd Participant are immediately eligible to maintain the account and utilize it m fund eligible medical benefits specified in Section X above. Upon notification of a Participant's death, the Participant's account balance will he transferred into Dreyfus Cash Management fund' (or another fund selected by the Employer). The account balance may he reallocated by the surviving spouse or dependents. An nrunnnrar in for Drryfw Caib Ahnnngrrnent money marker fund it notimnrtd orgrmrrrnrnel Ly the /'rdtral Deporit Imurrrocr Corporation or any uthergoventmtntagarry. A[though thef..id saki to prrsr a ile talar of your invrmnrrrr at Sl.00 prr rl7are, iris pmtible ro !we worry Lr invr+ring in the fisad. /nuatorr+Lordd rauida die imrrnnna uLjrrriro, rN, rher m and cvpn+srr ofrhr find nrrtfid�• Ltfore iovrnnrg. Yon nary nide ru ret wrmu.innerraorg or ra11800-669-7400 ro ahmiu n prorpram rL,tr rmrmiru rbinmd othn infornmtimr nLmrr thelineal. Rend duprmpanrsmrcfi ity Lrforrintoning. If a Participants account balance has not been fully utilized upon the death of die eligible spoine, 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 Vlll. B. No Surviving Spouse or Surviving Dependents M If thele 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 [anployerw•ill submit all VanrageCare 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 sub mission. This includes but is not limited to termination no[ificadon and benefit eligibility notification. B. Participant account administration and asset-based fees will be paid through the redemption of Participantaccount shares. unless agreed upon otherwise in the Administrative Services Agreement. is 25E-103 C. Assign mcnr of benefits is no[ 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 (a) the Participant's lawhil spouse, (b) the Parricipant:s child under the age of27. as dfi, by IRC Section 152(f)(1) and Interna( Revenue Service Notice 2010-33, or (e) arty other individual who is a person rn described in IRC Section 152(x), as clarified by internal Revenue Servicc Notice 2004-79. E. -Ihe 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 our this Employer Van[agcCarc Retirement Health Savings Plan Adoption Agreement may result in the loss of tax exemption of the -frust and/or loss of rax -deferred status for Employer contributions. B, Q Checl:_this box ifyou are including supporting documents that include plan provisions. By: IFn!7�( R'E By: �JJ// Date: Title: City Manager Clerk of the Council FEB 0 5 2015 Accepted: VANTAGEPOINTTRANSFER AGENTS, LLC APPROVED AS TO FORM !� t,•t LISA E. STORCK L d L.W`i%y Assistant City Attorney g Assistant ecretary, ICMA-RC 25E-104 ATTEST: It[f'y//�' ^^/ MARIAD HUIZA C( ERK OF THE COUNCIL FEB 0 5 2015 �0 Plan # 803550 ADMINISTRATIVE SERVICES AGREEMENT This Agreement, made as of the�t��l�day of I a vi Dlct Y Y 20 (herein referred to as the "Inception Date"), between The International City Management Association Retirement Corporation ("ICMA-RC"), a nonprofit corporation organized and existing under the laws of the State of Delaware; and the City of Santa Ana ("Employer") a local governmental instrumentality organized and existing under the laws of the State of California with an office at 20 Civic Center Plaza, Santa Ana, California 92702. RECITALS Employer acts as a public plan sponsor for a retiree health plan with responsibility to obtain investment alternatives and services for employees participating in that plan; Employer desires to make the VantageCare Retirement Health Savings Plan ("RHS Plan" or "Plan") provided by ICMA-RC available to its employees; ICMA-RC makes available The Vantagepoint Funds, a no-load, diversified mutual fund, for investment of public employer plan assets, including RHS Plan assets; ICMA-RC provides a complete offering of services to public employers for the operation of employee retirement and retiree health savings plans including, but not limited to, communications concerning investment alternatives, account maintenance, account record- keeping, investment and tax reporting, form processing, benefit disbursement and asset management. AGREEMENTS Acceptance of RHS Plan Employer agrees to make the RHS Plan provided by ICMA-RC available to its employees. The details of the RHS Plan shall be as mutually agreed between the Employer and ICMA-RC, and in general shall be as set forth in the RHS Plan materials developed by ICMA-RC and provided to Employer. The RHS Plan materials are hereby incorporated by reference and made a part of this Agreement, except that Employer and ICMA-RC may from time to time mutually agree in writing to terms that vary from the RHS Plan materials. RHS plan materials shall include the VanlageCare RHS Employer Nfanual, available electronically through the EZ Link System upon plan adoption. The functions to be performed by ICMA-RC and its agents include: (a) allocation in accordance with participant direction of individual accounts to investment finds ("Funds") made available to Plan participants; (b) maintenance of individual accounts for participants reflecting amounts contributed -2- 5 25E-105 Plan # 803550 income, gain, or loss credited, and amounts disbursed as benefits; (c) provision of periodic reports to the Employer and participants of the status of Plan investments and individual accounts; (d) communication to participants of information regarding their rights and elections under the Plan; (e) disbursement of benefits as agent for the Employer in accordance with terms of the Plan; and (f) performance of tax withholding and reporting in conjunction with the Employer for each RHS account. 2. Employer Duty to Furnish Information Employer agrees to furnish to ICMA-RC on a timely basis such information as is necessary for ICMA-RC to carry out its responsibilities with respect to the Plan, including information needed to allocate individual participant accounts to Funds, and information as to the benefit eligibility and employment status of participants, and participants' ages, addresses, dependents, spouses I and other identifying information (including tax identification numbers). Employer also agrees that it will notify ICMA-RC in a timely manner regarding changes in staff as it relates to various roles. This is to be completed through the online EZLink employer contact options. ICMA-RC shall be entitled to rely upon the accuracy of any information that is furnished to it by a j responsible official of the Employer or any information relating to an individual participant, spouse or dependent that is furnished by such participant, spouse or dependent, and ICMA-RC shall not be responsible for any error arising from its reliance on such information. ICMA-RC will provide reports, statements and account information to the Employer through EZLink, the online plan administrative tool. ICMA-RC Representations and Warranties ICMA-RC represents and warrants to Employer that: (a) ICMA-RC is a non-profit corporation with full power and authority to enter into this Agreement and to perform its obligations under this Agreement. (b) ICMA-RC is an investment adviser registered as such with the Securities and Exchange j Commission under the Investment Advisers Act of 1940, as amended. ICMA-RC I Services, LLC (a wholly owned subsidiary of ICMA-RC) is registered as a broker-dealer with the Securities and Exchange Commission (SEC) and is a member in good standing of the Financial Industry Regulatory Authority (FINRA). j I 3- q 25E-106 Plan tt 803550 4. Employer Representations and Warranties Employer represents and warrants to ICMA-RC that (a) Employer is organized in the form and manner recited in the opening paragraph of this Agreement with fill power and authority to enter into and perform its obligations under this Agreement and to act for the Plan and participants in the manner contemplated in this Agreement. Execution, delivery, and performance of this Agreement will not conflict with any law, rule, regulation or contract by which the Employer is bound or to which it is a party. (b) Information required to be retained by the Employer shall be set forth in the RHS plan materials developed by ICMA-RC and provided to.the Employer. (c) Employer is responsible for determining that there are no state or local laws that would prohibit it from establishing ICMA-RC's VantageCare RHS program. Employer is also responsible for determining that the investments selected for the RHS plan fall within state or local requirements. ICMA-RC shall not be responsible for monitoring state or local law or for administering the Plan in compliance with local or state requirements unless Employer notifies ICMA-RC of any such local or state requirements. (d) Employer acknowledges that the RHS plan may be treated as a "health plan" for Health Insurance Portability and Accountability Act ("HIPAA") purposes and therefore may be subject to HIPAA privacy rules. If it is determined that the RHS plan is considered a "health plan", an employer sponsoring RHS would be responsible for complying with the HIPAA privacy and security rules regarding protected health information of RHS plan participants. (e) Employer acknowledges that certain such services to be performed by ICMA-RC under this Agreement may be performed by an affiliate or agent of ICMA-RC pursuant to one or more other contractual arrangements or relationships, and that ICMA-RC reserves the right to change vendors with which it has contracted to provide services in connection with this Agreement without prior notice to Employer. (f) Employer acknowledges and agrees that ICMA-RC does not assume any responsibility with respect to the selection or retention of the Plan's investment options. Employer shall have exclusive responsibility for the selection and retention of the Plan's investment options, including the selection of the applicable mutual fund share class. 5. Participation in Certain Proceedings The Employer hereby authorizes ICMA-RC to act as agent, to appear on its behalf, and to join the Employer as a necessary party in all legal proceedings involving the garnishment of benefits or the transfer of benefits pursuant to a medical child support order. Unless Employer notifies ICMA-RC otherwise, Employer authorizes ICMA-RC to determine whether disbursement of Oil 25E-107 Plan # 303550 benefits to a spouse or child pursuant to a medical child support order is appropriate. Compensation and Payment (a) Absent an explicit agreement to the contrary between ICMA-RC and Employer, participant fees and expenses shall be payable from RHS assets, in accordance with the requirements of the RHS Plan as set forth below. (i) An annual asset fee of 0.40% (40 basis points) will be charged on a quarterly basis, based on the balance in the account on the last day of the previous quarter. In addition to the annual asset fee, a $25 annual account administration fee will be charged quarterly to each Accountholder's account. Account administration fees are subject to change with appropriate prior notification. (b) Annual account administration fees are subject to change with appropriate prior notification. (c) Compensation for Advisory and other Services to The Vantagepoint Funds. Employer acknowledges that certain wholly-owned subsidiaries of ICMA-RC receive compensation from The Vantagepoint Funds for advisory and other services furnished to The Vantagepoint Funds. The fees referred to in this subsection are disclosed in The Vantagepoint Funds Prospectus and Statement of Additional Information. Contribution Remittance Employer understands that amounts contributed to the RHS plan are to be remitted directly to Vantagepoint Transfer Agents in accordance with instructions provided to Employer in the RHS plan materials and are not to be remitted to the ICMA Retirement Trust or ICMA-RC. In the event that any check or wire transfer is incorrectly labeled or transferred, ICMA-RC will return it to Employer with proper instructions. Responsibility (a) ICMA-RC shall not be responsible for any acts or omissions of any person with respect to the Plan, or related Trust, other than ICMA-RC in connection with the administration or operation of the Plan. (b) The Employer understands that, as a general matter, the Internal Revenue Service ("IRS") may decline to rule on certain design features or provisions that the Employer may request to have added to the RHS plan materials. The Employer agrees to hold ICMA- RC harmless in connection with the addition and administration of any RHS plan feature or provision requested by the Employer for which the IRS will not provide express -5- 25E-108 Plan # 803550 interpretive guidance. 9. Indemnification Employer shall indemnify ICMA-RC against, and hold ICMA-RC harmless from, any and all loss, damage, penalty, liability, cost, and expense, including without limitation, reasonable attorney's fees, that may be incurred by, imposed upon, or asserted against ICMA-RC by reason of any claim, regulatory proceeding, or litigation arising from any act done or omitted to be done by any individual or person with respect to the Plan or related Trust, excepting only any and all loss, damage, penalty, liability, cost or expense resulting from ICMA-RC's negligence, bad faith, or willful misconduct. 10. Term This Agreement shall be in effect for an initial term beginning on the Inception Date and ending 5 years after the Inception Date. This Agreement will be renewed automatically for each succeeding year unless written notice of termination is provided by either party to the other no less than 60 days before the end of such Agreement year. 11. Amendments and Adiustments (a) This Agreement may be amended by written instrument signed by the parties. (b) The parties agree that only an adjustment to compensation or administrative and operational services under this Agreement may be implemented by ICMA-RC through a proposal to the Employer via correspondence or the Employer Bulletin. The Employer will be given at least 60 days to review the proposal before the effective date of the adjustment. Such adjustment shall become effective unless, within the 60 day period before the effective date, the Employer notifies ICMA-RC in writing that it does not accept such adjustment, in which event the parties will negotiate with respect to the adjustment. (c) No failure to exercise and no delay in exercising any right, remedy, power or privilege hereunder shall operate as a waiver of such right, remedy, power or privilege. II. Notices All notices required to be delivered under this Agreement shall be delivered personally or by registered or certified mail, postage prepaid, return receipt requested, to (i) Legal Department, ICMA Retirement Corporation, 777 North Capitol Street, N.E., Suite 600, Washington, D.C, 20002-4240; (ii) Employer at the office set forth in the first paragraph hereof, or to any other address designated by the party to receive the same by written notice similarly given. M 25E-109 Plan # 503550 12. Complete Agreement This Agreement shall constitute the sole agreement between ICMA-RC and Employer relating to the object of this Agreement and correctly sets forth the complete rights, duties and obligations of each party to the other as of its date. Any prior agreements, promises, negotiations or representations, verbal or otherwise, not expressly set forth in this Agreement are of no force and effect. 13. Governing Law This agreement shall be governed by and construed in accordance with the laws of the State of California applicable to contracts made in that jurisdiction without reference to its conflicts of laws provisions. In Witness Whereof, the parties hereto have executed this Agreement as of the Inception Date first above written. APPROVED AS TO FORM LISA E. STORCK Assistant City Attorney ATTEST: eARIAD�HUIAR ZAR ,', , t CLERK OF THE COUNC L CITY OF SANTA ANA By: Print Name: Edward S."aya Title: Executive Director, Personnel Services INTERNATIONAL CITY MANAGEMENT ASSOCIATION RETIREMENT CORPORATION UM Angela C. Montez Assistant Corporate Secretary 7- 25E-110