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INSURANCE NOT ON FILE A-2017-242 WORK MAY NOT PROCEED CLERK OF COUNCIL DATE: APR 16 2016 0 ) Service Level Agreement with Total Administrative Services Corporation SECTION I THIS SERVICE LEVEL AGREEMENT ("Agreement"), is entered into by and between Total Administrative Services Corporation ("TASC") and the Employer identified on the Group Services Plan Application ("Plan Application") as the Plan Sponsor, City of Santa Ana. This Agreement is effective on the date of the Plan Sponsor's signature on the Plan Application which is attachcd as Exhibit A to this Agreement. The terms of this Agreement apply to the Plan(s) and services identified on the Plan Application. The Plan Sponsor is duly organized, validly existing, and fully authorized to enter into this Agreement. The individual executing the Plan Application 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 to as the Plan Administrator), Plan Sponsor, Named Fiduciary and Plan Assets shall have the meaning given to such terms by the Employee Retirement Income Security Act of 1974 (ERISA), as amended. TASC is not the Plan Administrator, the Plan Sponsor, or a Named Fiduciary for any Plan Identified on the Plan Application. TASC does not accept a fiduciary role or status for any Plan. TASC is and will remain an Independent contractor with respect to all services provided. TASC and the Plan Sponsor are not partners or engaged in a joint venture. TASC does not collect or hold employee contributions or plan assets, B. All fees paid to TASC by the Plan Sponsor, regardless of the payment options selected, are paid from the general assets of the Plan Sponsor, C. TASC is nota law finar and is not providing legal or tax advice. All written or verbal communication provided under the terms of this Agreement are general in nature and not intended to constitute legal or tax advice. The products and services provided pursuant to this Agreement may have legal and tax consequences. Any questions regarding Plan Sponsor's particular needs, requirements, circumstances, or the tax consequence of any product or service offered under this Agreement must be directed to Plan Sponsor's own advisor(s) at the Plan Sponsor's expense. 2. Services Provided by TASC A. TASC shall use ordinary care and due diligence in the performance of its duties under this Agreement and provide timely administration and management of the Plan(s) Identified in the Plan Application as outlined in the applicable product administration manual and/or materials incorporated by express reference to this Agreement Services provided by TASC are subject to change upon written notice to the Plan Sponsor or as required by law. B. In the case of Ptex System, and TASC HRA Plans, TASC will also provide audit assistance support under the terms of the applicable Audit Guarantee. TASC may change any feature, function, brand, third party provider, or attributes of a Service, or any element of its systems or processes, from time to time, provided that such changes do not have a material adverse Impact on the performance or cost of the Service. 3. Responsibility of the Plan Sponsor A. The Plan Sponsor has final and complete discretion over the Plans. The Plan Sponsor Is the Plan Administrator under ERISA. The Plan Sponsor shall have the sole and Final discretionary authority in respect to all legal and administrative 2 functions of the Plan. The Plan Sponsor acknowledges and accepts sole responsibility for the payment of all Card Transactions. TASC can assist the Plan Sponsor in the recovery of Card Transaction amounts reported as fraudulent transaction activity by Participants, provided however that Plan Participants comply with the terms outlined in the cardholder agreement for 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, complete and timely manner, all relevant and requested information necessary or desired for administrative functions to be performed by TASC in a standard TASC format or an alternative format agreed upon by the parties. TASC shall rely on the accuracy and timeliness of Information provided to it by the Plan Sponsor. TASC has no responsibility to review or verify data provided by the Plan Sponsor. TASC is not responsible for detecting illegal acts by, and/or misrepresentations of, the Plan Sponsor's employees or representatives. TASC shall have no responsibility or liability for failure to provide any service for which the Plan Sponsor has not provided complete data to TASC in an agreed upon format. C. Failure to meet deliverable expectations, including but not limited to those noted above and elsewhere in this Agreement, in an accurate, complete and timely manner will result in a status of delinquency. Delinquency status will result in service interruptions and/or delays. TASC will have no liability for any losses due to the failure to perform during the time the Plan Sponsor is in delinquency status. 3 D. It is the Plan Sponsor's responsibility to educate and inform Plan participants on the services being provided, including the delivery of administration materials (where needed) as welt as compliance documents (e.g., Summary Plan Description). The Plan Sponsor is responsible for executing and retaining the Business Associate Agreement (where applicable) provided in the administration materials. 4. Financial Responsibility of the Plan Sponsor A. Responsibility for payment of all Plan benefits lies with the Plan Sponsor. All Plan benefits are paid from the general assets of the Plan Sponsor. Unless an alternative method of payment is mutually agreed upon by the parties, TASC Fees will be collected from the Plan Sponsor via ACH transaction and the Plan Sponsor hereby authorizes TASC to initiate credit/debit entries to the bank account indicated in the Plan Application and fiirther authorizes the Plan Sponsor's batik to debit the same to such account. If for any reason, TASC does not receive payment for any TASC fees detined on the Application within ten (10) business days of the Expected Date of Receipt TASC may place all Plan processing on hold until all past due TASC fees are paid. TASC reserves the right to charge a reasonable fee for all debit entries that reject for insufficient f nds or closed accounts. This authority will remain in full force until TASC has received written notification from the Plan Sponsor of its termination of this authority in such time and in such manner as to afford TASC and the Plan Sponsor's bank a reasonable opportunity to act on it. It is understood that the purpose of this authorization is to provide a means of payment for the administrative services provided to the Plan Sponsor by 4 TASC. Regardless of the fee payment options identified on the Application or any circumstances where the Plan Sponsor uses a third patty to pay Plan benefits, all Plan contributions and liabilities are the responsibility of the Plan Sponsor. B. TASC reserves the right to correct any processing errors, making a reasonable effort to recover any payment made in error for any reason and the Plan 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 Plan or to the Plan Sponsor as deemed necessary. TASC will interpret state unclaimed property laws in a reasonable manner to divest itself from Funds attributed to Plan participant reimbursement checks not presented for payment. C. The Plan Sponsor understands and agrees Plan Sponsor shall be liable for and hold TASC harmless from any and all fees or penalties assessed by the Internal Revenue Service, the Department of labor or any other federal, state and/or local government agency arising from the Plan; except in the case where It is shown that a loss is a direct result of a negligent act or omission on the part of TASC. Any request for refunds or adjustments by Plan Sponsor will be processed only after verification is made that sufficient funds were received by TASC from the Plan Sponsor's bank account to cover all payments made by, and fees and other amounts due to, TASC. No refunds or adjustments will be made while the Plan Sponsor is in default under this Agreement. 5. Terms of Pavment A. The Plan Sponsor agrees to pay TASC for services provided under this Agreement in accordance with the fees determined on the Plan Application. Payment for E services wilt occur via E -pay or invoices will generate prior to the applicable service period and are due according to the terms on the Invoice. In addition to the fees determined on the Plan Application, all interest on Plan fees shall be retained by TASC as a supplemental fee and such fees shall be considered earned at such time as any Interest accrues. B. Any Plan funding ACH debits that are rejected or which, for any reason, are not processed through the Plan Sponsor's bank will result in the Plan being placed in delinquency status until such ACH debit is properly processed or otherwise resolved. C. TASC may adjust administrative fees on an annual basis at renewal with thirty (30) days written notice of the fee change. 6. Default A. Either party shall be in default under this Agreement upon the occurrence of one or more of the following events: (i) the failure of that party to perform any material term, condition or covenant of this Agreement; (ii) the ceasing of the conduct of active business by the party; (iii) the institution of proceedings under bankruptcy or insolvency laws by, for or against the party, or the appointment of the receiver for that party or for that party's assets or properties, (iv) an assignment by that party for the benefit of creditors, (v) and an admission by that party of its inability to pay its debts as they become due, or (vi) non-compliance with law governing the transactions under this Agreement. B. Upon Default by either party that is non-compliant with applicable law governing the transactions under this Agreement, when the non-compliance could reasonably 6 result in an excise tax, penalty, or claims liability, all obligations of the non - defaulting party shall cease. No term of this Agreement can be read to extend the term of this Agreement beyond the day that a Party discovers such non- compliance. At the non -defaulting party's discretion, this Agreement can be continued upon satisfaction that the non-compliance has been rectified and the effected persons made financially whole by the non-compliant defaulting Party. C. TASC shall have no additional duties under this Agreement related to a Plan Sponsor who institutes proceedings under Chapter 7 of the Bankruptcy Code, or makes an appointment of a trustee or receiver for the disposition of their assets or properties, or an assignment of assets for the benefit of creditors, or an admission of its inability to pay Its debts as they become due. TASC will continue to administer services for such a Plan Sponsor through the earlier of the date on which the Plan Sponsors Plans terminate entirely, the date the Plan Sponsor is no Ionger able to continue their business, or the last period that TASC has been paid for its services. D. For all other incidents of default, the non -defaulting party may, at its option and by written notice to the other party, terminate this Agreement if the default remains uncured for thirty (30) days after the non-detaulting party provides written notice to the defaulting party of such default. If such default remains uncured, the termination is effective as explained below. Any termination shall be without prejudice to any other rights and remedies, which the non -defaulting party may have against the defaulting party with respect to such default TASC's obligations are subject to the Plan Sponsor's timely performance of its obligations and 7 responsibilities under this Agreement including but not limited to providing TASC with correct, complete and timely data or other information, or notices required under this Agreement; and to timely pay fees. E. TASC will not be responsible for any damages or losses due to a default by the Plan Sponsor. In the event of a default by the Plan Sponsor: 1) This Agreement maybe terminated and all amounts due and to become due to TASC shall become Immediately due and payable, at TASC's sole option; and, 2) TASC reserves the right to suspend all or any services to the Plan Sponsor and the Plan, including the reporting or processing of Plan data and payments, and 3) TASC will not be responsible for the timeliness or accuracy of any reporting, participant payments, tax deposits or payroll payments until the defaults) has been cured and all outstanding obligations the Plan Sponsor have been paid to TASC. 7. Termination and Renewal of Agreement A. This Agreement will renew automatically. Either party may terminate this Agreement with sixty (60) days written notice. If services are terminated under this Agreement, the Plan Sponsor will be responsible for providing any outstanding services required under the Plan. B. Notwithstanding the term described above, ACA Employer Reporting will continue for a l2 -month initial term, thereafter renewing automatically for one year terms. Either party may terminate this Agreement with sixty (60) day written notice. C. If services are terminated under this Agreement for reasons other than a TASC 8 uncured default or TASC material non-performance, the Plan Sponsor will be responsible for providing any outstanding services required under the Plan and payment of the ACA Reporting fees until the end of the calendar year in which the termination Occurred. In case of terminations, there are no refunds of the set-up fee, and no refunds of any fees applied to the service for the calendar year in which the services are tenninated. D. Either party may tenninate this Agreement due to a default by giving the defaulting party ten (10) day written notice of the termination .If the non - defaulting patty allowed a thirty (30) day cure period the ten (10) day written notice will be at the end of the cure period. E. Upon and after the expiration or termination of this Agreement, the rights granted to the Plan Sponsor pursuant to this Agreement shall revert back to TASC. TASC may provide the Plan Sponsor with sample forms, procedures, scripts, marketing materials or other similar information (collectively, "Materials"). Plan Sponsor shall have a license to use Materials, if any, solely in connection with its use of the Services, Software, or Deliverables during the term of this Agreement and solely in a manner that is consistent 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 use. The Plan Sponsor shall refrain from any further direct or indirect use of or reference to TASC marks, systems, publications, manuals, brochures, documents and computer databases in connection with the marketing, use, implementation, 9 license, sale or distribution of any program, system or Plan offered by TASC. F. Finally, the termination of this Agreement shall not affect the duty of the Plan Sponsor not to infringe on TASC's trademarks and copyrights and not to disclose and keep confidential all said confidential information supplied to the Plan Sponsor by TASC. S. Confidentiality If TASC receives from the City information which due to the nature of such information is reasonably understood to be confidential and/or proprietary, TASC agrees that it shall not use or disclose such information except in the performance of this Agreement, and further agrees to exercise the same degree of care it uses to protect its own information of like importance, but in no event less than reasonable care. "Confidential Information" shall include all nonpublic information. Confidential information includes not only written information, but 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 party is covered by this Agreement. The foregoing obligations of non-use and nondisclosure shall not apply to any information that (a) has been disclosed in publicly available sources; (b) is, through no fault of the TASC disclosed in a publicly available source; (c) is in rightful possession of the TASC without an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (e) is independently developed by the TASC without reference to information disclosed by the City. 9. Insurance TASC shall provide Plan Sponsor a certificate of insurance demonstrating professional liability insurance coverage with a combined single limit of not less than $1,000,000 per claim l0 with $2,000,000 in the aggregate prior to the start of work pursuant to this Agreement. The following requirements apply to the insurance to be provided by TASC pursuant to this section: A. TASC shall maintain all insurance required above in full force and effect for the entire period covered by this Agreement, B. Certificates of insurance shall be furnished to the City upon execution of this Agreement and shall be approved by the City. C. Certificates and policies shall state that the policies shall not be canceled or reduced in coverage or changed in any other material aspect without thirty (30) days prior written notice to the City. 10. IndemniFcation A. TASC shall indemnify the Plan Sponsor, its directors and officers, and hold it harmless from and against any and all actions, claims, lawsuits, settlements, judgments, costs, taxes or similar assessments, penalties and expenses, including reasonable attorney's fees, resulting from.a direct result of TASC's negligence or willful misconduct. B. The Plan Sponsor shall indemnify and hold TASC, its directors, officers, employees, agents and assigns harmless from and against any and all actions, claims, lawsuits, settlements, judgments, costs (including but not limited to, costs of insurance premiums paid with respect to the Plan), taxes or similar assessments, penalties and expenses, including reasonable attorney's fees, or other obligations resulting from, arising out of or in any way connected with the Plan, including any prior administration of the Plan or a similar arrangement, or claims or demands by Plan Participants and/or beneficiaries ("Losses"), unless the Losses are directly attributable to TASC negligence or willful misconduct. C. Each party's indemnification obligations are conditioned on the following: 1) If process is served, the indemnified party providing written notice within five (5) business days of receiving service of process regarding an indemnifiable event, 2) If the party receiving indemnification is required to make any admission or pay any consideration as part of a settlement, no settlement shall be made without such party's consent, and 3) The indemnified party cooperating in the defense and/or settlement of the indemnifiable event. Subject to the limitations set forth in the immediately preceding section of this Agreement, the parties' indemnification obligations hereunder shall survive the termination of this Agreement. 11. Records TASC shall keep records and invoices in connection with the work to be performed under this Agreement. TASC shall maintain complete and accurate records with respect to the costs incurred under this Agreement and any services, expenditures, and disbursements charged to the City for a minimum period of three (3) years, or for any longer period required by law, from the date of final payment to TASC under this Agreement. All such records and invoices shall be clearly identifiable. TASC shall allow a representative of the City to examine, audit, and make transcripts or copies of such records and any other documents created pursuant to this Agreement during regular business hours. TASC shall allow inspection of all work, data, documents, proceedings, and activities related to this Agreement for a period of three (3) years from the date 12 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 interests, direct or indirect, which would conflict in any manner with performance of services specified under this Agreement. 13. 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 prohibited by applicable law, in the recruitment, selection, training, utilization, promotion, termination or other employment related activities. TASC affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 14. Defense of Legal Actions TASC shall notify the Plan Sponsor of any legal action arising with respect to the Plan of which TASC becomes aware. Other than a regulatory claim that is defended by TASC under an applicable Audit Guarantee provided to the Plan Sponsor in writing from TASC, the defense of any legal actions shall be the responsibility of and be undertaken at the expense of the Plan Sponsor, it being understood and agreed that TASC shall cooperate with and assist the Plan Sponsor in said defense, at Plan 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 and all express warranties, warranties of fitness for a particular purpose and implied warranties of merchantability. TASC will notbe liable in contract or in tort for any loss of business orprofits, or for any consequential, incidental, punitive, or similar damages, or, other 13 than set forth in this Agreement, for any claims of damages made by any third party for any reason whatsoever, even if TASC has been advised of, had other reason to 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 any mistake of judgment or other action taken in good faith in the performance of the services provided hereunder, or for any loss or damage occasioned thereby, unless the loss or damage is due to TASC's negligence or willful misconduct. C. Notwithstanding any other provision of this Agreement, and for any reason, including breach of any duty imposed by this Agreement, including but not limited to the indemnification obligations set forth above, or independent of this Agreement, and regardless of any claim in contract, tort (including negligence) or otherwise, TASC's total, aggregate liability under this Agreement shall in no circumstance exceed $1,000,000.00. D. No action, regardless of form, arising out of the services provided under this Agreement, may be brought by the Plan Sponsor more than two years after the date the last services are provided under this Agreement. Each parry acknowledges that these limitations of liability reflect an informed, voluntary allocation between the parties of the risks (known and unknown) that may exist in connection with this Agreement. 16. iVdoney Back Guarantee If you are not entirely pleased with the Phan, simply return all Plan materials within thirty (30) days or the date received to obtain a refund or the related fee, less the $100 nonrefundable minimum fee. The Money Back Guarantee does not apply to any TASC Compliance Service 14 Offering, to include: TASC ACA Employer Reporting, TASC ERISA, TASC HIPAA, TASC PCORI, TASC Form 5500 Preparation, TASC Non -Discrimination Testing, and TASC Medicare Part D Notices. No refunds will be issued for these services. SECTION II In addition to the preceding paragraphs of Section I, the following terns and conditions shall be applicable depending on the Plan elected by the Plan Sponsor. 17. FlexSvstem A. All claims submitted to FlexSystem other than substantiated copayments, recurring medical expenses or debit card charges substantiated in real time through an inventory Information approval system, or through other means compliant with Internal Revenue Service regulations, must be substantiated by independent third - party information prior to claim payment. If, at any point, the Plan Sponsor makes the decision to adjudicate Plan participant claims, all claims and substantiation submitted to TASC by Plan pafticipants shall be forwarded to the Plan Sponsor for review prior to payment of the claim by TASC. If Plan Sponsor does not reject the claim within three (3) business days of receiving the forwarded claim, TASC shall pay the claim. TASC reserves the right to request a deposit or payment if the Estimated Claims Fee determined on the Application is, or is likely to be less than the amount necessary to process Plan benefits. TASC will require a deposit or payment for negative Plan participant account balances or potential negative Plan participant account balances upon termination of the Plan. B. Plan fees are the greater of the stated minimum or per Plan participant fee. Fees are also calculated on the number of Plan participants in the Pian, including terminated 15 employees. At the time of invoice, the Plan Sponsor is responsible for administration fees for the entire Plan Year, including carryover or grace period, as applicable. Failure to remit Plan participant funds or payment for administrative services will result in a disruption of services, the forwarding to collections and/or ternlination or all services provided by TASC under this Agreement. C. FlexSystem is designed to administer HIPM excepted and non -excepted health FSA plans. A non -excepted health FSA may be subject to HIPAA portability, a full COBRA offering of 18 or 36 months, and certain of the health care reform requirements under The Patient Protection and Affordable Care Act. The Plan Sponsor who offers a non -excepted health FSA is responsible for ensuring their plans meet all applicable regulations for non -excepted health plans. The additional requirements are not covered under the Audit Guarantee. 18. TASC HSA A. TASC provides administrative services to assist Plan Sponsor in. offering its eligible employees the option to open Health Saving Accounts (HSA). Plan Sponsor acknowledges that TASC is not qualified to act as a trustee or custodian of the HSA funds and is not acting as such. TASC provides the Health Savings Account (HSA) services pursuant to an agreement with one or more third party financial institutions that serve as custodian and trustee of the HSA Funds ("Custodian'). TASC is not responsible for claims, damages or liabilities arising from failure of Custodian to perform its obligations or provide resources as required by its agreement with TASC (Custodian is, however, liable for failure to perform its obligations). 16 B. Plan Sponsor represents and warrants that, to the best of its knowledge, the group health plan sponsored and maintained by Plan Sponsor pursuant to which medical coverage is provided to its employees electing to open a HSA with Custodian will be, at all times relevant to this Agreement, an HDHP, in accordance with 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 employees and held by Custodian shall not be employee benefit plans and the assets held in the HSA shall not be plan assets subject to the provisions of ERISA. Plan Sponsor acknowledges and agrees that at all times relevant to this Agreement participation in HSAs by employees shall be completely voluntary; and Plan Sponsor shall not: (i) limit the ability of participants to move monies In their HSAs to another HSA (except to the extent of restrictions imposed by the Code; (ii) Impose any conditions on the utilization of EISA monies beyond those permitted by the Code; (iii) represent or advise that the HSAs are an employee welfare benefit plan established or maintained by the employer; or (iv) receive any payment or compensation in connection with an EISA. Plan Sponsor acknowledges that TASC may, from time to time, change the Custodian and may subcontract other aspects of its performance. TASC may not, however, require any participant to close an EISA with 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 HSAs, other than to allocate the contributions In accordance with clear instructions received from Plan Sponsor, participants, or other contributor or transferor. TASC shall have no 17 obligation to take affirmative actions to collect monies paid as contributions, such as, by way of example, to pursue a check or electronic payment transfer from Plan Sponsor or a participant or other contributor or transferor that does not clear. If this Agreement is terminated mid plan year, Plan Sponsor shall continue to be responsible for payment of administration fees set forth in the Plan Application for the entire plan year. Administration fees shall be calculated on a minimum or per participant basis, whichever is greater. For purposes of calculating fees on a per participant basis, the number of participant shall be determined as of the invoice date and shall include any employees terminated mid -year. In addition to the administration fees set forth in the Plan Application, TASC shall also be entitled to payment from the Plan Sponsor of all expenses and costs reasonably incurred by it in the administration of the HSAs, including, but not limited to, reimbursement for the cost of debit card transactions. 19. TASC HRA -NOT APPLICABLE Fraudulent claims by Plan participants (regardless of whether by use of the debit card, web submitted, TASC submitted, medical provider or manually submitted) and amounts distributed to Plan participants that exceed the Plan participants' account balances are the Plan Sponsor's responsibility, unless the overpayment is due to a negligent act or omission on the part of TASC. TASC also reserves the right to request a deposit or payment when the fund account goes into a negative account balance. Fees are calculated at the Minimum Claims Fee identified on the Application or enrolled fee whichever is greater. Fees are also calculated on the number of health enrolled in the Plan, including terminated employees at the time of invoice. The Plan Sponsor is responsible for administration fees for the entire Plan year, including the thin -out period. Standard 18 cvn-out period is ninety (90) clays following the end of the Plan Year. In the event that prescription drug coverage is offered under the Plan and to the extent that the Plan Is an ERISA employee welfare benefit plan, Plan Sponsor shall be solely responsible for determining whether the prescription drug coverage is creditable or non -creditable coverage for Medicare Part D purposes, on either a stand-alone basis or in conjunction with another group health plan. In such event, Plan Sponsor shall also be responsible for providing disclosure notices to Medicare Part D eligible individuals who are covered under or apply for coverage under the Plan advising whether the prescription drug coverage provided through the Plan, either on a stand- alone basis or combined with another group health plan, is creditable. 20. TASC COBRA -NOT APPLICABLE TASC and the Plan Sponsor agree to the terms that are described in the TASC COBRA Client Administration Manual (or the COBRA Client Administration Manual -state continuation if the Client is retaining TASC COBRA for state continuation), and accept the responsibility to perform the functions that are listed on the Services and Responsibilities checklist. These Forms are incorporated by reference. TASC will provide appropriate notices to participants in a format and manner that is consistent with federal or state law and regulations pertaining to continuation. TASC will be entitled to assume that all the covered persons reside at the address of the employee provided by the Plan Sponsor, unless the Plan Sponsor provides alternative addresses. TASC will monitor the following cleadlines, election periods, premium payment grace periods, COBRA enrollment requests, and Social Security extension requests. TASC does not have the discretion under this Agreement to allow any exceptions to legally established deadlines, TASC will retain the 2% administrative fee charged to participants for continuing coverage. 19 The Plan Sponsor has the responsibility to review the monthly reports sent to the Plan Sponsor by TASC and reports that are available on line to ensure data has been received and COBRA election notices sent. These reports are also notices indicating enrollment changes that are needed for participants, which can include reinstatements, terminations, and plan changes. The Plan Sponsor will make the necessary changes in a timely manner to effectuate coverage with the applicable insurance carrier or third party administrator, unless an alternative enrollment communication arrangement has been made and agreed upon between the parties. In cases where the Plan Sponsor is making the enrollment changes with the insurance carrier or third party administrator, TASC will not have any liability for any losses Including premium or claims payments due to a Plan Sponsor's failure to make the enrollment changes when the enrollment change was communicated to the Plan Sponsor by monthly reporting or an alternative agreed upon method. In cases where TASC has agreed to make the enrollment changes with the insurance carrier or third party administrator, TASC will not Have any liability for any losses including premium or claims payments for a period beginning thirty (30) days after the enrollment change was communicated to the Plan Sponsor by monthly reporting or an alternative agreed upon method. Plan Sponsors who are'small employers' as defined by applicable State law may, under the federal Affordable Care Act ("ACA"), have a premium rating method that can include: age bands that may require mid plan year premium rate changes; a differential for smoking tobacco products; a differential for geographical location; and itemized billing by the Insurance carrier for each person covered under a membership. Unless another method of administration is agreed upon, the Plan Sponsor will need to send to TASC the actual individual rates billed by the insurer for each 20 person who is covered under the Plan (employee, covered spouse and dependents as indicated on the carriers itemized bill) on the day before a COBRA Qualifying Event, or State event if State Continuation services are provided under this Agreement. This will be an additional data item required for the continuation administration, and all of the terms of this Agreement addressing data submission will apply. TASC will not be responsible for any excise tax, penalty, premium, or claims costs, clue to failing to send a timely Election Notice when the data forwarded by the Plan Sponsor did not include the actual individual rates, The Plan Sponsor will notify TASC of any mid -year premium rate change required by the premium rating method when applicable to their Plan. TASC will have no liability for any premium losses due to the failure to send new coupons with the increased rate, except when timely notice of the change has been received from the Plan Sponsor. 21. TASC Ftr'ILA-NOT APPLICABLE The Plan Sponsor agrees, as is necessary for TASC to complete its responsibilities 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 cannot carry out its responsibilities without notification as defined, with relations to the Plan Sponsor's employees. 1) Absences, or proposed absences, in excess of three (3) days from regularly scheduled work for the circumstance (s) of a birth, adoption or placement in foster care of a child, the care of a seriously ill child, spouse or parent, or the employee's own illness, 2) Eligibility of the proposed employee; employment by the Plan Sponsor in excess of 12 months and cumulative work hours of 1,250 in the preceding 12 months, 3) Notification to TASC if an employee who has been out on leave has returned to work. The Plan Sponsor must provide to TASC and keep TASC currently informed, of all pertinent information relating to the Plan Sponsor at the inception of the contract and as may be 21 later modified by the Plan Sponsor, including but not limited to: 1) Advise TASC of any changes in employee population per location that may affect FMLA administration (increase or decrease with relation to the minimum of 50 employees per covered location), 2) Advise TASC of any newly acquired locations, in order to ensure compliance with FMLA administration, 3) Advise TASC of any divested location (closing or stile to separate organization) that affects FMLA administration, 4) Provide TASC with current information regarding all benefit programs; provider's rates and other pertinent information. TASC and the Plan Sponsor agree to the teens that are described in the FMLA Client Administration Manual (including State Family and Medical leaves if subject), and accept the responsibility to perform the functions that are listed in the above paragraph. 22. TASC ACA Employer Reporting -NOT APPLICABLE ACA Reporting requires the Plan Sponsor to make initial and annual determinations, referred to in the ACA Reporting Manual as "Determining Your Status under the ACA." TASC recommends these ACA determinations made by the Plan Sponsor and reported to TASC be reviewed by the Plan Sponsor's Benefits Advisor, Broker, or Benefits Counsel. The TASC Audit Guarantee does not cover any 4980H penalties due to the failure to make accurate determinations. TASC is not responsible for any 4980H penalties clue to activities that occurred, or the failure to act, prior to the beginning of the Agreement with TASC. Complete information on the Group Business Plan Application and complete monthly data must be provided to TASC prior to the fifteenth day of December so TASC may meet federal timing limits. TASC is not responsible 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 responsibilities herein, to timely provide the TASC with all applicable Plan and Benefit information to include any insurance certificates, ASO certificates, plan summaries and the like needed for incorporation in the Plan Document/Summary Plan Description. The Plan Sponsor will make any and all 22 determinations and disclosures as to their membership in a controlled group of corporations, a group of businesses or trades Under common control or an affiliated services group. The determination of whether such group can be included in a single plan document or multiple plan documents and any resulting Form 5500 obligation(s) will rest solely with the Plan Sponsor. The Plan Sponsor is responsible for making the determination as to the filing of any delinquent Form 5500 returns, including plan year for which any return is required and the number of plans in place during the period of delinquency. The Plan Sponsor is responsible for the payment of any fines and penalties which may arise in connection with any of delinquent returns, unless the delinquency status of a return is due to TASC negligence or failure to perform and all of the required data was delivered to TASC no less than fifteen (15) business days prior to the filing due date. The Plan Sponsor or its agent will timely provide the information necessary to complete the applicable Form 5500 return, including participant counts and any applicable Schedules and or auditor reports needed for the completion of the return. The Plan Sponsor understands they are responsible for notifying the TASC in a timely manner when certain plan changes occur.. The Plan Sponsor understands . that Plan Documents/Summary Plan Descriptions provided are lawyer authored boilerplate legal documents designed to fulfill the Plan Document and SPD requirements under the Employee Retirement Income Security Act (hereafter ERISA). These Plan Documents/SPDs are not customizable for governmental plans, church groups or other entitles exempt from ERISA. Customization of the document is limited to a standard set of required information and may not meet the needs of plan sponsors with complex plan designs and/or funding arrangements or those requiring customization above and beyond the standard set of required information and at a level usually provided by contracted legal counsel. The Plan Documents/SPDs provided are written for health and welfare plans subject to ERISA. Pension and retirement plans are outside the scope of this product. 23 24. TASC PCORi Compliance -NOT APPLICABLE The TASC PCORI Compliance offering will assist you in completing federal tax Form 720, Quarterly Federal Excise Tax Return, to report under the Affordable Care Act the patient - centered outcomes research (PCOR) fee on health plans. TASC is not a Tax Preparer under the federal rules and can only assist you in completing the Form 720.The Plan Sponsor will file IRS Form 720. 25. TASC HIPAA Compliance -NOT APPLICABLE The TASC HIPAA Compliance offering is intended to assist the Plan Sponsor in establishing and documenting compliance with federal privacy and security rules as mandated by HIPAA and HITECH. TASC is not engaged in rendering legal or accounting services, and no such service or advice is being offered in this product. When seeking such legal advice or other expert assistance, a competent professional should be engaged. If you self-administer your self - fended plan(s) and maintain medical records for claims proposes then this product will not bring 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 Included services and any additional services as selected by the Client. TASC shall use ordinary care and due diligence in the performance of its duties under this Agreement and provide timely administration and management of the Give Back Plan as outlined in the applicable product administration manual and/or materials incorporated by express reference to this Agreement. This Agreement for GiveBack will renew automatically. Either party may terminate this Agreement with thirty (30) days written notice. If services are terminated under this Agreement, the Employer will be responsible for providing any outstanding services required under the Plan. 24 Either party may terminate this Agreement due to a default by giving the defaulting party ten (10) day written notice of the termination. If the non -defaulting party allowed a thirty (30) clay cure period the ten (101 day written notice will be at the end of the period. SECTION III This section applies to all plans. 27. Execution and Delivery The Plan Application is incorporated herein by reference and may be executed and delivered by facsimile or Portable Document Format (PDF) transmission) in one or more counterparts, all of which will be considered one and the same agreement, and this Agreement will become effective when the Plan Application is signed by a representative of the Plan Sponsor. Any such facsimile or PDF documents and signatures shall have the same force and effect as manually signed originals and shall be binding on the Plan Sponsor/Plan Sponsor and TASC. 28. Governing Law This Agreement shall be construed,, governed by, and enforced in accordance with the internal laws of the State of Wisconsin without giving effect to the principles of comity or conflicts of laws thereof. 29. Entire Agreement This Agreement represents the entire agreement of the parties and supersedes any prior written or oral agreements. This Agreement shall not be altered or amended, except by written agreement of duly authorized representatives of TASC and the Plan Sponsor. 30. Attorneys' Fees In any action at law or in equity to enforce any of the provisions or rights under this Agreement, the non -prevailing party in such litigation, as determined by the court In a final judgment or decree, shall pay to the prevailing party or parties all costs, expenses and reasonable 25 attorneys' and accountants' fees incurred therein by such party or parties (including without limitation such costs, expenses andfees on any appeals), and if such prevailing party shall recover judgment in any such action or proceeding, such costs, expenses and fees shall be Included as part of such judgment. 31. Notices A. Any notice, demand or other communication required or permitted to be given to either party to this Agreement shall be in writing and shall be either personally delivered by hand or delivered by prepaid courier or sent by electronic means such as facsimile, telex or electronic mail. B. Any notice personally delivered or delivered by courier shall be deemed received upon delivery. C. Any notice sent by electronic means shall be deemed received upon the date the sending tenninal confirms that the notice was received. D. The address to which communications shall be sent to the Plan Sponsor is Identified in Section lofthe Plan Application. Either party may change its address by giving written notice to the other party as provided in this subsection. 32. Assignment This Agreement may be assigned, delegated, or transferred without the prior written consent of either party unless a party makes a reasonable claim that the performance of obligations under the Agreement will not be honored. The assigning party will provide a notice of assignment including information identifying the assignee within thirty (30) days of the assigmnent. A reasonable claim that the performance of obligations under the Agreement will not be honored must be received within fourteen (14) days of the date of the assignment notice described in this paragraph. Notwithstanding, such consent shall not be necessary in the context of an acquisition by asset sale, merger, change of control or operation of law. This Agreement shall be binding on 26 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 obscrvam party of any term or condition of this Agreement shall not affect. thefull right f 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 privilege. 34. Severability If any.term or condition of this Agreement is held to be Invalid or unenforci of any statute, rule o f law or public policy, all other terms -and. conditions of this ? remain in full force and effect as if this Agreement had been executed with unenforceable portion. eliminated. ATTEST: CITY OF SANTA ANA ,7 MARIA HUIZAR RAUL GODIN l'I�� t Clerk of the Council s;-� City Manager APPROVED AS TO FORUM: SOMA R. CARVALHO City Attorney Br s .A-.k�� �- Laura A, Rossini Senior Assistant City Attorney RECONEMENDED FOR c� ED RAYA Executive Director of Personnel (Signatures continue on next page] 27 by She other require such aiv�r of any or reason it shall or TOTAL ADNI1NISTRATIVE SERVICES CORPORATION in �-- (Nome) (Title) 28 EXHIBIT A PLAN APPLICATION 29 I�4 S N Please submit completed Application with required fees to: 0791M�' Email -f X Mail _TASC, We New Business Department newbuslness@tasconline.com (608) 661-9638 2302 International Lane, P.0, Box 14140 Contact Name: Cattle Hanes Email Title: Telep Company Name: City of Santa Ana Busing Physical Address: (nop000x) 20 Civic Center Plaza, M-34 CILY: Mailing Address: (no Po Box) City: NAICS/SIC Code: [3 TASC Suite # Nature of Business: city Government Cl TASC ACA Employer Reporting El TASC HRA Tax Filing Stat= U C -Corp Q S -Corp El PartnershlD Q Sale Prc tjneaten insurance Larrier: : Qa1PLRS Medical Carrier AM/Rep Name: irl Yveft Fields ne: 1(714) 647-6967 Federal ID#: Santa Ana State: ICAZip: �92702 State: f Zip- i Total 4 Employees; i)72- - --------- Total 9 Benefit Eligible Employees: 245 'fetor U iNlor_-_Pro1ltC_1LLC - _01l IDU: � 4843991156 RenewaTDate: Na p Email; yfields@keeman.com Are ! 12 No If Yes, please provide your 12-DigitTASC ll)h Min you a current TASC Client? _U_Yes_l Name existing/ac ASqse services es: I Annual Select the new TASC service offering(s) for this application (and complete each corresponding section under PART 6 FlexSystam FSA Set Up res $ 300 check the boxesfor each TASC Suite Add -On Offerings loptional): complete app section for sale tI..;.-j [3 TASC Suite # Included offering below Cl TASC ACA Employer Reporting El TASC HRA A complete each section EJ TASC Non -Discrimination Testing 0 TASC HSA within this application. U TASC Form 5SQ0 Preparation ENEFITACCOUNT MANAGEMENT SERVICES BENEFIT CONTINUATION SE RVICES F4 2 FlexSystem FSA C3 TASC COBRA Q QB Takeover 17$ 11 FlexSystem POP C1 TASC FMILA D Eligibility Determination SECTION E 0 Transit Account SECTION A ....... �4.25 $ 100 $ COMPLIANCE SERVICES W Parking Account 0 TASC ACA Employer Reporting (2 -yr contract) SECTION F 0 TASC HSA -Full El TASC ERISA Q TASC HSA -Limited SECTION B El Medicare Part D Noticesi j Q TASC HSA Plan only El Late 5500 Filing 13 PPACA Notices SECTION 6 j 0 TASC HRA -Full Q Carrier Certificate ClAdd WrapDoc (s) 0 TASC HRA Debit Card SECTION C Q TASC PCORI (with TASC ERISA -free) Q TASC HRA -Self Q TASC PCORI (without TASC ERISA) SECTION H 0 TASC GiveBack SECTION I. Form 5500 Preparation SECTION I --------------------❑TASC TASC Non -Discrimination Testing SECTION J TASC Funded ll plan application El TASC HIPAA SECTION K Enter each Service Offering selected In PART 2 and the applicable fees In the pricing chart below: New Service Offerings: One Time -7 --mn's—t'r—�t —on 'Ad Min Annual Additional Services aq FlexSystam FSA Set Up res $ 300 I Fees $ 4.25 Admin Fee oqo_L $ I Re nawal Fees 1 and Fees -$ F4 TOTAL FEES 17$ � 300 �4.25 $ 100 $ too Page I Employer Initial ,6TASC TC -3923-010117 Select a payment method for your fees due and complete the following Information for the selected payment method. Payment Method Aptlons' ` ACH (E Pay)' Credit Card' Involced _ Set-Up Fees: .n. ❑ N/A DUE NOW for all services Administration Renewal, • Not Available Admin Fees DUE NOW for. TASCHIPAA ACA, POP, Self-HRA ❑ I� and Additional Fees: ^ ALL FEES DUENOWforTASCERISA Information for Payment Methods ._ ___ �. - wFinandal institution Name:_sP Marean chaso&co. ..a_..e...e. _ m�State: (cA ___. _._- - -_._ __... . .. ACH (E-Pay) Information: Bank Routing # (9 digits) _ ;322271627 Checking Acct # 7661062375 Routing and account numbers are typically located at the bottom left turner of a blank check from your bank (varies). The roudn numberis always nine (9J di Rs long and enclosed bycolons. M LJ MasterCard ❑ Visa ❑ American Express ❑ Discover Card #. Exp. Date: Credit Card information: - _- -_- -- -- -� - - - - Name onnCard: ID Signature. ..,_,a__._..........�..„__....., Frequency: 0 Quarterly ❑ Annually (1-15 Employees defaults to Annually) ......._. ._n„._...�m�.>,.. B Same address from Section 1 ❑ Different address: Invoice Information: Bdling Contact Name: Mall to:Email: _.._ _. ......._ _ .. _.. _._.._ ... Street Address: ! City .State: zip: 'e -Pay Is TA. US stanaam metnoa ror suomisslon or aumrnistrationlees. With E -Pay, TASC conveniently deducts your fees from your checking account. Simply complete the box above, signing where Indicated. Please note ACH Information for each benefit's plan funding will need separate attention in their respective section of the application. All written debit authorizatlons must agree that the Payer may revoke the authorization only by first notifying the Originator In the manner specified in the authorizatlon. The language In the authorization represents the disclosure requirement associated with the clarification of OFAC economic sanction policies upon ACH Network Participants. 'Credit Card payment option is only available for fees submitted with this completed Plan Application. It is not avallable for future billing payments. This Group Plan Application Is a binding agreement between Total Administrative Services Corporation ("TASC') and you and, if applicable, the company or other legal entity you represent (collectively, "you"). By signing this Group Plan Applicatlon below, you accept the terms of the Service Level Agreement. You also accept the TASC HIPAA Privacyoffering as Indicated in Part 2 above for applicable service offerings and you acknowledge receipt of the attached HIFAA Business Associate Agreement signed by TASC that assures compliance for your records. Further, you, as Plan Sponsor and Plan Administrator, and on behalf of, the plan set forth in this Group Application, hereby appoint TASC and/or its subcontractors or agents to act as an authorized agent for purposes of receiving and/or retrieving electronic reports/responses ("Claim Feed Information") from the insurance carrier(s) listed in this Group Application or otherwise identified by you on your behalf. TASC and/or its subcontractors or agents use and disclosure of Claim Feed Information shall be subject to the terms of the Business Associate Agreement, IMPORTANT NOTE: The TASC ACA Employer Reporting term will continue for a 12 -month initial term, thereafter renewing automatically for one year terms. Early termination fees are described on page 15, under Termination and Renewal of Agreement. I have read, understand and agree to the terms and conditions stated in this Group Plan Application, the Service Level Agreement, and the Business Associate Agreement (if app cable) /,�,s�attested by the signature below, effective on the date of the signature. xDEmployer Signature: "0 X' Date: -z' (—rt Title: Executive Director of Personnel&I-vices Distributor/Agent Name: (Keenan &Associates MyTA Primary Account Rep Name: Yvette Fields ; Emall: INTERNAL USE ONLY: Assist MYTASC ID: 4709-1480-9358 1 Retail Code: Paget Employer InitialTASC TC -0823.010117 qll Select all benefits made available to the eggible employee(s).. These benefits are taken through salary_ deductions. 0 Healthcare FSA- Medical Expense Reimbursement Account: $ 2600 Maximum Election (Employee & Family) Is employer-sponsored group health insurance offered to employees? ®Yes 0No»rfNO, you are not eligible tooffer this benefit. ® Dependent Care FSA Reimbursement Account: Maximum $5,000; $2,500 if married filing separately (Employee & Family) 8 Non -Employer Sponsored Premium Reimbursement (NESP): For qualified Individual Premium Plans not offered through any employer. Is employer-sponsored group health insurance offered to employees? ®Yes 0No»/fNo, you are not eligible tooffer this benefit. • Medical or Medical -Related Premium: Group Sponsored (Employee & Family) ® Voluntary/Group Term Life Insurance Premium: Up to $50,000 in death benefits (Employee Only) ® Disability Insurance Premium: Pre -taxing employee contributions will make benefit taxable compensation (Employee Only) 0 Supplemental Insurance: Includes cancer, hospital confinement, Intensive care, accidental death and dismemberment (Employee & FamlIvI Medical/Office: JS�$-�C) ------- - -'- - -�5 Prescription Drug: -$-- $ A_DMINISTRATIVE6PTIONSforTRANSIT/PARKING�ry _ _ m. f.............._,,.,_.�... x._...u....._,,.�_..,_._.._...v._..... If applicable, select options below for your TASC Transit and/or Parking Account. Defaults are based on the current IRS monthly maximum. Each optlon can be selected fo_r either or both benefits, EXCEPT_ the Terminal Restricted Card must ap ly to both accounts. _ Transit AccountW_� parking Account B Rollover ❑ LJ Restriction: Rollover Reimbursement Restriction IJ Terminal Restricted Card Days (190 default) _ _. Days (180 default) (applies to both Transit and Parking) Page Employer Initial ',�a(EiT Sc TC -3923-e10117 Set -Up Fee (due now) T^ ® Flexible Spending Account (FSA) Full Administration PRICING INFO; I • Admin Fee -per participant, per month __ __ ______ _ ____ ___ __ __ r _ -7 • Annual Renewal Fee ❑ Premium Only Plan (POP) Administration ^�J __` PRICING-INF6. • Admin Fee -per group, peryear (due now) ❑ Transit Reimbursement Account (T/P) --------- T • No additional fee w/flex5ystem Full FSA PRICING INFO -- ❑Parking Reimbursement Account (T/P) .� • Admin Fee -per participant, per month • Annual Renewal Fee PLAN.INFORMATION :_� FullFSA- POP TransitAccount Parking Account Number of Eligible Employees (each): ❑ No W Yes Existing Plan in Place? - -- ❑ No Yes U No CI Yes W No 0 Yes - - - ----- -- - - If YES, please complete the following: _ ERISA 3 Digit Plan ft + - _ - I rv/A _._ f N/A H of Current Participants tss _ 135 Name of Current Administrator conexls It - conexls PLANOPTIONS :.....�:. f.:t._._._.,.......,__V..,,...®...__,w..............._m,.......-_.,,..,....m..�._.,__..�_,FS_7/P„) ....�.._.m Select options below and enter the information foryour Current Plan NEW Plan applicable_ current and new Plan(s): _ - - 0 Healthcare FSA Carryover (default $500) Carryover $: Carryover $: 500 ❑ Grace Period(default 2.5monti If Health Carryoverls GP End Date: GP End Date: ^—J—l— _—f—f— also elected, Health FSA will be exdudedfrom Grace Period. iiRunoutPeriod (default 90 days after Plan End Dote) pO End Date I RO End Date Runout for afl trenefltsendon same date (_ -_ _,—/— Select administrator for current FSA Plan Grace Period and Runout: ❑ Prior Administrator U TASC' 'IMPORTANT; Obtain the FlexSystem Takeover Checklist fer Information that be received belore Plan start date with TASC. Carryoverdata from a prior Administrator must be provided to TAscotter the pdorNon Year Runout has ended with the applicablefunding. AVAILABLE FSA PLAN TYPES-,. Select all benefits made available to the eggible employee(s).. These benefits are taken through salary_ deductions. 0 Healthcare FSA- Medical Expense Reimbursement Account: $ 2600 Maximum Election (Employee & Family) Is employer-sponsored group health insurance offered to employees? ®Yes 0No»rfNO, you are not eligible tooffer this benefit. ® Dependent Care FSA Reimbursement Account: Maximum $5,000; $2,500 if married filing separately (Employee & Family) 8 Non -Employer Sponsored Premium Reimbursement (NESP): For qualified Individual Premium Plans not offered through any employer. Is employer-sponsored group health insurance offered to employees? ®Yes 0No»/fNo, you are not eligible tooffer this benefit. • Medical or Medical -Related Premium: Group Sponsored (Employee & Family) ® Voluntary/Group Term Life Insurance Premium: Up to $50,000 in death benefits (Employee Only) ® Disability Insurance Premium: Pre -taxing employee contributions will make benefit taxable compensation (Employee Only) 0 Supplemental Insurance: Includes cancer, hospital confinement, Intensive care, accidental death and dismemberment (Employee & FamlIvI Medical/Office: JS�$-�C) ------- - -'- - -�5 Prescription Drug: -$-- $ A_DMINISTRATIVE6PTIONSforTRANSIT/PARKING�ry _ _ m. f.............._,,.,_.�... x._...u....._,,.�_..,_._.._...v._..... If applicable, select options below for your TASC Transit and/or Parking Account. Defaults are based on the current IRS monthly maximum. Each optlon can be selected fo_r either or both benefits, EXCEPT_ the Terminal Restricted Card must ap ly to both accounts. _ Transit AccountW_� parking Account B Rollover ❑ LJ Restriction: Rollover Reimbursement Restriction IJ Terminal Restricted Card Days (190 default) _ _. Days (180 default) (applies to both Transit and Parking) Page Employer Initial ',�a(EiT Sc TC -3923-e10117 Employer Contributions? 0 No ❑ Yes Payroll/Funding Cycle (select one): ❑ Weekly ❑ Bi -Weekly 0 Semi -Monthly ❑ Monthly ❑ Other: _ 9 Contributions in 12 -mo Plan Year: Participant Contribution Schedule: Dates applied to Participant, accounts based -a - n above selected payroll cycle. (based on Plan Funding schedule below for Y` Contribution: __I 21° Contribution ��J— Last Contribution I ) zJZi7 the Estimated Date of Recelpt (EDR)) Other cvdes: Entry and Probationary Period: Selectthe employment requirement below that an eligible employee must meetin order to enroll in the FlexSystem Plan at open enrollment, or atthe time of hire: ❑ On the date of hire ❑ 1" of the month after date of hire ER 30 days after date of hire ❑ 1" of the month after 30 days of continuous employment ❑ 60 days after date of hire ❑ 1" of the month after 60 days of continuous employment ❑ 90 days after date of hire ❑ Other: ._._included Excluded NA_..,� ❑ ❑ O Members of bargaining units Additional Requirements: (selectallthatapply) ❑ — 0 E Part-time employees regularly scheduled to work at,least—hours perweek ❑ ❑ ❑O - Seasonal employees regularly working at least. months within a year ❑ ❑ ❑O ( Emolovees under vears of a¢e This Section defines the Estimated Claims Fee (ECF) method utilized to make benefit payments to your FlexSystem Participants. The ECF Is calculated by determining the total contributions for the Plan Year (employee and employer) and divide that total by the number of payments scheduled under the Expected Date of Recelpt (EDR). This fee Is adjusted as applicable for mid -year enrollment and election changes. If the total ECF collected for the Plan Year results in excess fees greater than paid claims for that Plan Year, the excess will be returned to the Plan Sponsor as forfeiture under the Plan. Any fees or charges described in this section are in addition to the fees due under Part 2: TASC Services and F,�. To start this rocess: (1) ch000se funding process, (2j vert your Expected Date of Receipt, and (3) enter your bank Information: —...�._--_.__..�....___.__.___._ __...___..._._... (1) ! U TASC ACH (default): TASC Initiates funding payment via ACH on the EDR. ❑ Client MyTASC Funding: Clientinitiates funding payment via MyTASC on orbefore the EDR.Note: Under this option, TASC will use yourAccount and Routing Numbers To post any unpaid funding amounts that are one (1) business day past the EDR. Also, additional annual fee will apply If ACH Is not elected ($10.00per payroll). (2) Verify your Expected Date EDR is the payroll contribution schedule Indicated in the Plan Contribution section for each payroll cycle. This Is the date of Receipt (EDR): that TA5Cw1ll pull an Auto ACH from your designated account and apply the payroll contributions to your Participant's _ accounds). This may ormaynot he the same date as the Partic)pant's payrof) deduction date. (3) Bank Information: ❑ Use same ACH info from Part 4 of this Application ❑ Use different ACH information as per below: Financial Institution Name: State: Bank Routing Number (9 digits): Checking Account 9: ADMIN ONLY: FlexSystem - Special Instructions: Page Employerinitialy/ ��{'T�iSC TC,3923-010117 b----- rj�tivl•gl` N'hRk r'r 19 3t,7Fr»rj+Yyn jf S 1S.,'.f G..« f.�tr3{ •. EsSu�"s'eS.S.Ic�.., n�i�ifi� �. 1isi7f�l"tay�aN'r�7pfatt iz�F.po.ta�'uruljuaoyFq�a,^a�ia'.. FULL I LIMITED I PLAN ONLY Number of Eligible Employees: Existing HSA in place? ❑ No ❑ Yes Existing Health FSA in place?ElNo ❑ Yes Ell Limited Health FSA - - -- - la IfYES, Indicate the Plan Type: . ❑ Limited Post -Deductible Health FSA ❑ General Purpose Health FSA +Limited Health FSA ❑ General Purpose Health FSA+ Limited Post -Deductible Health FSA Note: If you implement an HSA on a different Plan effective date than your existing Health FSA then you must amend your entire Health FSA to a Limited or Limited Post - Deductible Health FSA. Amend the Plan by downloading and completing the adoption of the TASC Plan Document as Instructed In your Welcome Kit. All participants are moved to the amended Health FSA. The IRS will not allow mid -year participant election changes. At your next open enrollment you can crier Health FSA, options. FULL I LIMITED # of EE Payroll Contributions: Payroll/Funding Cycle: ❑ Weekly ❑ Bi -Weekly _ _ C] Semi -Monthly ❑ Monthly ;_ El Other: -, _J—f_— 2" Contribution: �� payroll — - Participant Contribution Schedule; -- - - 1" Contrtbutionateso ie to Participant accounts used on above Last Contnbutlon mpioyer Contributions?: ❑ No ❑ Yes if YES, please complete all information below: Contribution Amount per Coverage Level: Single: $ Family: $ Frequency of Employer Contributions: 13 One Time: Contribution Date: ❑4V - — -- eekly ❑ Bif -Weekly ❑_Semi -Monthly El Monthly O _ Employer Contribution Schedule: I" Contribution: 24 Contribution: Far banking holidays, select one option:, ❑ Apply contributions next business day ❑ Apply contributions prior business day Pro -Rated for Mid -Year Enrollees?:❑ No ElYes If YES select a method below. ❑ As of Plan Start Date ❑ As of -Most -Recent Quarter ❑ Other: FULL I LIMITED I PLAN ONLY HSA Plan Start Date: / (mo/dd) HSA Plan End Date; PLAN FUNDING _ _ _ _ _ _ _ _ _ FULL To fund your HSA Plan, TASC will initiate ACH debits from the bank account and financial institution named below. Plan funding payments will be electronically deducted from the indicated bank account and automatic --- - ally submitted on your scheduled payroll contribution dates. ---_---- m --n your Bank Information: ❑ Use same ACH Info from Part of this. Application ❑ Use different ACH information as per, below: Financial Institution Name: Branch:; Bank Routing Number (9 digits): Checking Account N: ❑ 1 understand the pay dates can NOT be changed once the Plan is enrolled ❑ 1 understand TASC will send an email prior to withdrawing funds for my account and that I should contact TASC with any changes no later than three (3) days prior to the employee's payroll date. Disclaimer fora stand-alone HSA Plan (not combined with TASC FlexSystem): TASC has developed a service known as 'TASC HSA" that provides full administrative services for Health Savings Accounts. Itis understood that the client wishes to add the HSA to its current Sectlon 125 Plan and that the client acknowledges they have amended their Section 125 Plan to Include the required HSA language to allow HSA contrlbutlons to be pre -taxed and thele Section 125 Plan Documents and SPD's are current according to Federal Law. ADMIN ONLY: TASC HSA - Special instructions: Pages Employer Initial - T.LSSC TC -3923-010117 gy "ir a' I Select one TASC HRA Plan to apply for and complete the requested information for that Plan Type (noted by corner tabs): ❑ TASC HRA Full Administration Set -Up Fee (due now) AdditionaiServiies; PRICING • Admin Fee– per participant, per month -- -- - INFO: 1 • Annual Renewal Fee El TASC Debit Card (included atno charge for First Dollar Plans) {, j • Based on number of employees PRICING ° No Set -Up Fee��� LJ TASC HRA Self -Administration • Admin Fee–per group, peryear (due now) INFO ---�.....__._�,-,__....®.m._ - • Annual Renewal Fee Pt A_N INFORMATION Estimated Number of Participants: I Number of Employees (FT+PT) to determine CMS Reporting Requirement: Existing HRA Plan in Place? : ONO CYes If YES, please provide the following information: ERISA 3 -Digit Plan #: # of Current Participants: Name of Current Administrator: – -- _ Current Run -Out Period: ; Days Who will administer current Plan Runout? ! Q Prlor Administrator ❑ TASC Select,one eligibility requirement below: 13 Eligibility requirements include participation in the named Health Insurance Plan(N/AforQualified Small Employer HRA Plans); or ❑ Eligibility requirements include (select off that apply below): O Part-time employees working at least —hours of work per week will be Included (maximum 29 hours) O Current employees completing _months of service with the employer will be included (maximum 90 days) 0 New employees Completing_ months of service with the employer will be included (maximum 90 days) h Flivihilih, ronuiromonh<_r1TVlFR• PLAN DESIGN ..®.�. ,.,._,. ............_..._ ....,..,.-..—...__....��........�, Fuu SELF. m_.. -._.,..,. Each...... Plan Design selected requires a separate Plan Application. Administration fees and funding arrangements apply to each Application. HRAPIan Design Options one perA pl/catlon) 3 Budget Plan Funding, ❑ by Member (embedded deductible) _ _ _ _— _ .._. ❑ Plan 1: Medical Deductible Only - At 25% The TASC Budget Plan Funding Fee is calculated as a percent of the aggregate annual benefit ® PIan2 Medical Deductible&Prescription At 50% under the TASC HRA Pion. To calculate plan also applies to Deductible Onfy Plant presmiptions apply toward the deductible/ -funding take Total Exposure x Funding %/12 Plan 3: Medical Deductible & Co -Insurance At 50% months. ❑ Plan4 Medical Deductible Co -pay &Prescription At S0% Regulataryllmits for QSEHRA: -. lfyou do not see your desired Plan Design, ❑ PIanS Medical_Deductible,_Co-Pay, Co -Insurance &Prescription __. At 50°% please Cali TASC at 1.800.422.4663 to discuss ❑ Plan 6: Uninsured Medical (must be Integrated with GHP) At SO% Plan setup. ❑ PIan7 QS EH RA Uri insured Medical At 50% Plan 8: QSEHRA Medical Insurance Premiums At 75% ❑ by Family Aggregate ❑ Plan 9 QSEHRA Uninsured Medical & Individual Insurance Premiums At 75% HRA tiRE1M6URSEMENTSw.....,a...._.....: Fuu 5E4F, .......::....:M......��._............®........._...,....._....m.......ea._._..,........_......�.a.,®.,....�.m,t TASC HRA Plan Participant Responsibility: Individual: $ - ❑ by Member (embedded deductible) (amount porticipant is responsiblefor prior to reimbursements) Family Maximum: $ ❑ by Family Aggregate Percentage T Amount Ranee TASC NRA/Employer Reimbursed _ _Dollar % ($ $ ... -__ J $ TASC HRA/Employer Reimbursements: Regulataryllmits for QSEHRA: _. $ -- Single Family �0—�.=--.-------_--$ -$4950; -$10,000 --1$$___--- Max. reimbursement per individual:$ - --------- I] by Member (Imbedded deductible) Max. reimbursement per Family: $ ❑ by Family Aggregate Page Employer Initial �';'cI10TASi- TC3923-010117--------- PLAN START euu se�F Select and complete one of the following two options Indicate the Plan Year dates and when TASC HRA ad minlstration begins. ❑ New HRA Plan (no current plan exists) 1`r Year Administration 21a and Successive Years Plan Start Date 1 First day of: J (mo/yr) First day of _ it Consecutive Months Continued i _ Twelve (12) month period Note: Plans need notrun on the calendar year (Le. January 1 -December 31J .._...._-...._.__.._..., _....._d..._ __.,_._._ -__._...._..___._....____.r.___.__..,. -...__.._..-_.__...,._W_-_....___..-.-._.._..___ Mid -Year Plan Takeover -select one setup option below (Year -to -Date balances must besubmitted with enrollments In order to beentered): ❑ Full Plan Year setup; or Plan Sponsor must submit an aggregate balance report of participant claims paid year-to-date to adjust the Participant HRA balance ❑ Short Plan Year setup; (less than 12 months) Plan Sponsor mustsubmlt an aggregate deductible creditreport ofparticipant claimspold year-to-date to adjust the Participant HRA balance. Allows you to extend a deductible credltto your Participants based on the amount of the health Insurance deductible that has been ^MrnN-J (mo/ddlvr) —-/ Current TASC HRA Plan: v Enterplan dates based an our selected setup: Plan Start Date _Plan End /A To fund your TASC HRA Plan, TASC will initiate ACH debits from the financial institution and bank account named below. _._.._-_ ...__.—... .--..- --- ---- __--. - ---- - ---........ -----'- _ _. Bank Information: ❑Use same ACH info from Part of this Application ❑Use different ACH Information as per below: Financial Institution Name: _ Branch: Bank Routing Number (9 digits): Checkine Account It: ADMIN ONLY: TASC HRA - Special Instructions: 'rY �q raj .11Nfil rlq MA A9, 8'522 M by Jnr *;ri'ay{t� Eh "liTdr iy n i� d a& R �',;1 r 'vy�birifir%'r Jl .(` "' Rk �gy� S, ''.PeFs',��'bf 3-r-'d'Iq.p,r r ti+Av"iGePs, L1 Y h rTt '%ktiktxa ..9Va �. �,Illl,+Jbkri .4+rai`1L�r'...,r.`LSP'16e'lP%�'I:.a�?�'i.-5fsu3�la�a w^'�.w'.15�eI�:nod Naii ❑ COBRA Administration & Compliance Additional Premium Collection Farm Is required with completed application before Pion can 6e setup. ; • Set -Up Fee (due now) NOTE: The - _,. PRICING . •Admin Fee -per HE, per month pal Service9_(additionaffeesapply); INFO: •Annual Renewal Fee ❑ Takeover Qualified Beneficiaries (TQB) COBRA Enrollees • Based on number of employees (Submit Takeover Qualified 9eneflclaryform(s)foreach TOO with completed amlimNon) _ PLAN IIMURMA HUN , Number Employees on Health Insurance Plan: ! _' Total Number of Employees (pro_-r_ate_forPT): (Current countneededforbillingpurposes) Current C_OB_RAA_dministrator. j OSelf ❑Other: SUBSIDIARIES, AFFILIATES or DIVISIONS-. Identify all subsidiaries affiliates, or divisions to Include under TASCCOBRA and if they require a separate setup forservice communications Name: --- -- -Separate Name: Separate lj O 3) ❑ _ 2) ❑ 4) .. _. ❑ PLAN ART _ .�;_..._...-.,...... -- - - - .....,.�...m�_- Enter the month and yearthat the Plan Year. will start for the fast year of TASC C08RA administration: TASC COBRA Plan Application must be received by 15th of month prior to this start date. _�_ (mo/yr) Plan Start Date: 'First day of: COBRAAddendum is needed ifrequested plan start date does notmeet this requirement. COBRA Period Begins: O First of month, following qualifying event - ❑ Other (please specify below) O Day after qualifying event _ ADMIN ONLY: TASC COBRA - Special Instructions: Page Employerinitlal iTASC TC -3933-010117 L— �•.a3.�i�`.:Idla' � �. J;�i�.��"�.6:�a z�wi^�2�ry ����'�e�i sr,�` i,� . a iry -.�'a.F�� ������ nur�vr �=r�lka'a �r�t1.x'r,. a�..e ��� �yhAsr.'J��r.a ❑ FMLA Administration & Compliance set -Up Fee (due now) -- - - • Admin Fee— per employee, per month Additional Services (odditiond/feesappfy): PRICING _.._. at -. _. INFO: (No Minimum) ❑ FMIA Eligibility &Entitlement Determination gree of charge within a TAS .1 I •Annual Renewal Fee select one: Q Submit eligibility file permonth ❑ Submit eligibility file Der event PLAN INFORMATION Number of Employees -_ _ - �Number of Company Loccatiations. Number of EES currently on FMLA Leave: Enter Location Name(s): (additional fees apply per takeover at imple-mentation) _ Current FMLA Administrator (enterbelow): Enter any States doing commerce: ' ❑Self ❑TPA: ._._.— Reporting per Location? ❑ No ❑ Yes (next question FMLA to run concurrent with Workers ❑ Yes _ .. Compensation and Short-term Disability Plans ❑ No If YES enter locations and contacts Method of Reporting FMLA Hours: ❑ Manual Report (via onfineform) ❑ Data Feed (via recurring f le from your timekeeping system for FMLA time used) FMLA 12 -month Tracking Type (select one): ❑ Rolling Backward ❑ Calendar Year ❑ Rolling Forward ❑ Plan Year w/Start Date of / / TASC FMLA Plan Start Date: ADMIN ONLY:TASCFMLA- SpecialInstructions: Plan Application to this startdate. 1 VR7,"t i('r rlr "_ a xr w+ •€ r-* uP+ sa wr% )t {�1(y��aip+re„ (o- a� F 7(� v �5sfi�r 1 L3:bue1� aKrPn�n�k�.x�iE:.au'c4�t.u,a:�,:r-r.^£'e�, t'ws"t`).T` ❑ ACA Employer Reporting (Z -year contract required) • Set -Up Fee (due now) • Annual Admin Fee (due naw) • Based on number of emPlove REQUIRED: Please select your Employer type and the appropriate service offering selection for your ACA Reporting needs: ❑ Single ALE or Government Entity (one EIN): ❑ Aggregated ALE (more than one EIN); Controlled Group or Government Entity C1 Non ALE (under 50 FT employees): Contact Name: ❑ Comprehensive Plan (includes Variable Hour Tracking) Q Reporting Only ❑ Comprehensive Plan (includes Variable Hour Tracking) Q Reporting Only Employee Mandate Only Email _.......- . I File Frequency: ❑ Monthly File ❑ Per Payroll File I ❑ ALE with Insured Medical Plan Applicable Large Employer (ALE) Status ❑ ALE with Self Insured Medical Plan Q Non ALE with Self-insured Medical Plan (10948 and 1095B Filing) »no Medical Planbates-jforRrevlousselectLon)_� If you are a "NON -ALE" with Self -Insured Medical Plan you DO NOT need to Provide the information below. Please Indicate whetheryou will be including the optional services below (response required forpricing): Variable dour Tracking ❑ yes ❑ No Minimum Essential Coverage offer Indicator: Q Yes Q No The TASCACA€mployer Reporting Administration Manua/will help you answer any ofthe following items that you ❑ Qualifying Offer Method have not. already determined. Select only those that apply (leave blank if unsure): ❑ 98%Offer Method Paged Employer initial 61C_`Tf15C Tca9za-010117 ______ ..-__' '011 Aggregated ALE:Information Controlled Group: Please indicate If you are a member of any of the following: (requlred) ------- ----- ..._-----..-------- • a Controlled Group of business entities under IRS Section 414(b) or (c); ❑ No ❑ Yes » If Yes, see below* • an affiliated service group under IRS Section 414(m); or - • an arrangement described under IRS Section 414(0) Government Entity: Are you area Government Entity that has reportable employees under ❑ No ❑ Yes » if Yes, see below* more than one EIN number? "if you answered YES to either question above, please complete the Information In the section below for each member entity within t h a Aggregated ALE,placing the entity with the most employees on top descending down to the entity with the fewest employees, A Plan Application will need to be submitted separately for each entity. _ Entity's Legal Name Entity's EIN Number I I `there are more than 15 entities to report, please provide the remainder on an additional document. T ADMIN ONLY: TASC ACA - Special Instructions: ��t°t�a.�5•�„.ria_a.,^���..,�.n.:..�.�,.,,,s-rc:€ld'.,.d_-�x�.c-...a'v�4,�s,.v.>3,�5'd��?At�"k��.c.-.fi�3s�" iw:.��e,W� �'.,.k� �'F� tt}�.��7u,�S�rM�� iihBi'aniia� ❑ ERISA Compliance Services PRICING ' Set-up Fee (due now) NOTE: Plan cvdl begrn on the fast of the month In which application Is received. •Annual Admin Fee (Na Minimum) (due now) _. .. _ .._ ....._ __. . INFO: ; Additional Services (additional fees apply): Based on number of employees ❑WMedlcare Part D Notice' ❑ PPACA Notices' ❑ Form 5500 Late Filing (ft of years to be filed: ❑ Additional Benefit Plans (9+) ❑ Professional Services (billed hourly) ❑ Wrap Document'- Individual/Separate Affiliated Employer ❑ Carrier Certificates of Coverage attached to Plan Document/SPD 'Services automatically renew annually p 'only select if additional Wrap Documents are needed beyond Included Mega -Wrap Document I nCRICCITC IRICrIp RflATIr1RI����P��Ta��K�wf) The following benefits are subject to ERISA requirements. Please complete each column as it relates to all benefits offered by the Employer, IMPORTANT NOTE: Your Plan Document/Summary Plan Description (SPD) will be prepared based on your answers to each question so please be sure to answer these questions accurately and In agreement with the insurance certificates or summaries for these benefits. Those Insurance certificates and summaries will be Incorporated by reference in your Plan Document/SPD and in effect comprise an Important part of your Plan Document/SPD. Refer to KEYbelow for each column: Column A: Applicable health & welfare benefits subject to ERISA- Indicate by completing all columns B -G for benefits offered by Employer. Column B:! For each applicable benefit offered, enterthe Month and Date forthe ACTUAL Contract Year of the policywith each carrier. Example:Health-- Contract Year is January 1, renews everyJanuary l - Column C: Is the Contract for this benefit Issued in the group name or individual? Enter "G' for Group, or "I" for Individual, Column D: For applicable benefits offered, are employees allowed to pre-tax their contributions underyour Section 125 Plan? Enter "Y" for ves. or "N" for no. Page Employer initial G�l T03923-010117 — -- IBI I (CI (o) (E) (Pi (G) -. Contract Benefit Contract Pre -Tax Insurance Carrier or Is Benefit 1 Total 0 of Covered Year Written to Group Benefit Service Provider Name : Self -Insured (SI), or I Participants ,.� (mo/dd/yr) I (G)orindividuais(i) II,! (Y/N); Fully-Insured(FI) (not Including Health Dental Vision Life AD&D STD LTD Voluntary/ Supplemental Life or AD&D Wellness—�-----._—..--_�._ Employee Assistance Program (EAf Stop Loss Insurance Voluntary Products Other ERISA Plans` "Other ER15A Plans: check wltu your compliance advisor to determine Lir these Plans are Employer Sponsored Plans subject to ERISA. Examples Include Prepaid Legal Services, Scholarship Funds, Day -Care Centers, Vacation Benefits, Apprenticeship orother Training Benefits, Holiday/Severance Benefits, and Housing Assistance Benefits. Is Entity part of: - a Controlled Group of Corporations under Code Section 414(b); 0 No - a Group of Businesses/Trades under common control under Code Section 414(c); or ❑ Yes (see next question) - an Affiliated Services Group under Code Section 414(m) ❑ No 4 Separate applications are required. If YES, are Benefits/Premiums paid from a single source? -❑ Yes 4 All entitles maybe under one Application. Under PPACA, current Group Health Plan is considered (selectone): ❑ Grandfathered (GF) ❑ Non -Grandfathered (NGF) _ Indicate if both Items apply below: 1. You are considered an Applicable Large Employer (ALE) under the Employer Shared Responsibility provision of the Affordable Care Act (ACT), and; O Yes ❑ No 2. You currently track employee hours to determine if any variable hour, part-time, or seasonal employees are "full- time" employees for purposes -of health plan eligibility Medicare Part D Coverage: O No ❑ Yes 4 Prescription Drug Plans, Offered_ ❑ Creditable ❑ Non- Creditable ❑ Both ADMIN ONLY: TASC ERISA -Special Instructions: ❑PCORICompliance Services (with TASC ERISA -free) PRICING ,,, No Set -Up Fee Cl PCORI Compliance Services (without TASC ERISA) INFO: • Annual Admin Fee (due now) • Based on number of emDlove (1),RESLIUl -FUR IN FUtiMATIUN- Select all that apply to your current benefits and status: ❑ (A) Health Reimbursement Account (HRA) ❑ (B) TASC HRA Client ❑ (C) TASC Non -Excepted (Health) Flexible Spending Account (NEFSA) Client ❑ (D) Self -Insured Health Plan ❑ (E) TASC HRA Self-Adm_Inistration Client /TASC Self -_Administration NEFSA Client_ If you checked ONLY boxes A and B and/or C, you can skip Part 2 below.` Page 10 Employer Initial `/''t)j�`�''',.'""°i71'ASC- TG1923-010117 - ` �II30 Enter the following Participant counts (see Instructions below on how to count Participants): 1st day of the 1st month of your Plan Year: --._--- ----_-Part --_.. Participant 1st day of the 4th monthof your Plan Year: Part _ count as of: 1st day of the 7th month of your Plan Year: _ arta_ 1st da of rhe 10th month of our Pian Year: INSTRUCTIONS for Participant Count (based on answers in Part 1 above): Box A ONLY, Box A and E ONLY, or Box C and E ONLY BOTH Box A and D, or BOTH Box C and D Box D ONLY *Include all COBRA Participant counts should equal the total number of HRA or NEFSA Plan Participants* on the first day of each quarter during the Plan Year. . Participant counts should equal the total number of self-insured Health Plan Participants* on the first day of each quarter during the Plan Year. Count each Health Plan Participant with self -only coverage and then add to that the number of Participants with other than sel f only coverage multiplied by 2.35 (the same Plan Year is assumed for both your HRA and self-insured Health Plan). ...Part__. .._.e r- - Part__. ___-__ _.._--.. ___._._..- Participant counts should equal the total number of self -Insured Health Plan Participants* on the frst day of each quarter during the Plan Year. Count each Health Plan Participant with self -only coverage and then add to that the number of Participants with other than self only coverage multiplied by 2.35 icipants In your count but do not Include any spouses or dependents that maybe covered under the Plan. ADMIN ONLY: TASC PCORI - Special Instructions: ❑ IRS Form 5500 Preparation PRICING ! * Annual Admin Fee (due now) INFO: r Based on number of benefits (additional fee 8*) __. _.. _. _. Part. + Late Filing for Form 55007 ❑ No ❑ Yes If YES. enter number of late filings: 5500 Plans, not for customers who are getting 5500 prep with another offering, If only/ate filing ADMIN ONLY: TASC Form 5500 Prep - Special Instructions: kk�*1�5 ! rBr.K+t`''rfi3+' ^"r 3rr y i�1 e4?m en,.`Es M�i�I`m'mrs.ylt"u�,�'+'��)'dS u s- Jad.S�Z.v'�v�.'wSfi+..t1}4u'H+v`r.fJ'�t PRICING '; ' Set -Up Fee (due now) El Non -Discrimination Testing -. Annual Admin Fee (due now) INFO: Based on numberofamnlova Select aILI t at apply, an n tate t e starten ates or Plan Year to be tested: _- Start Date: End Date: ❑ Premium Only Plan (POP) (Section 125 PI an): Eligibility Test, Contributions & Benefits Test- Availability&Utilization, Key Employee Concentration Test - __—.. —)�— —)—)-- ❑ Flexible Spending Account (FSA) - Dependent Care (Section 129 Plan): Eligibility Test, Contributions & Benefits Test, More than 5% Owners Concentration Test, 55%Average Benefits Test _ ____.. _... _. -. 13 Flexible Spending Account (FSA) - Medical: Eligibility Test, Benefits Test ❑ Health Reimbursement Arrangement (HRA): Eligibility Test, Benefits Test ❑ Self -Insured Medical Plans: Eligibility Test, Benefits Test ❑ Group Term Life Insurance: Eligibility Test, Benefits Test Note: Group employees of all entities must be tested if entity Is a member of a controlled group of corporations, trades, orbusinesses under common control or on affiliated service. ADMIN ONLY: TASC Nan-Discrim Testing- Special Instructions: Page a Employer Initial TG3923-010117 r�� +kism tNslS"rtY sr� r �, �" i�Cd* cM�ir}Yn-3 oak irx�p ry�in�.. tl R ncs a rrv+F w r r I fj S � v� :ar ma t ui '. '.-r i'<'n�13E ik. lY.1 + ,, �� 9 .',�#+�Ji"`�'7 ';,:n,5fx. ila'k �."���'.u9Fn�1 }��i�V��f�1��i� r]"NU Nirl�„ Mom 4.0+ mr%. a, i rn. ❑ TASC HIPAA Compliance Services PRICING I • No set -Up Fee NOTE: Plan wilt begin on the first of the month in which application is received INFO: • Annual Admin Fee—flat rate (due now) i 111 • Annual Renewal Fee (billed outomaticollv) ADMINONLY:TASCHIPAA- SpecialInstructions: .p`m' wi f��'�? rmt else �R irr���err r°!�n°W�'�J�r?��k i+, 1 YrI FM1' a a. .5�ei.1.tre�ir+.'.u'mrftr>`�tr�f.sk..s�ix�aru �.r ,`�iap,.t.Sde�.n«�u�kar7 E7ii+eA11.�}kl�.0 r?�ii�d. 4� { .... ,01141Nawr 3�ii Mu..ail1... • Set -Up Fee (due now) ❑ TASC GiveBack (Workplace Giving Administration) PRICING ! • Admin Fee - per participant, per month INFO::. • Monthly Maintenance Fee Annual Renewal Fee PUA I' F611 ION Number of Eligible Employees: "Yf4Yi1 yry`"""` Payroll/Funding Cycle (select one): ❑ Weekly 0 Bl -Weekly p Semi -Monthly 0 Monthly ❑ Other: # Contributions in 12 -mo Plan Year:- ParticipantContributionschedule: Contribution dates may or may not be the same date as payroll dates: the ed Estimated Plan ate of Receipt chedule eipt(Ebelowfor 1" Contribution: ,_)_/_ 2°a Contribution ` _f_f_ Last Contribution: the Estimated Date of Receipt (EDR)1 First Year Administration to begin: first day of: _/_ mo/yr)Completed Plan Applications mustbe received by the 15th of the month prior to this start date. Company Match: 0 . _,......__.. ,..._ to _ ximum.Matc for _ -....bell .. _ No ❑Yes if Yes enter Maximum Match for each below: -Per Employee, Per Year: $ Per Payroll $ 1 Enrollment Bonus: ❑ No ❑ Yes if Yes, enter Company. Enrollment Bonus amount: $ Hold a Fundraiser: 0 No 0 Yes fCOmoonv fundraiser or featured emofovee fundralsarl This Section defines the method that your Plan will utilize to make payroll and payroll matching (as applicable) payments to TASC. Any payments described in this Section are In addition to the fees due under PART 3 (Fees). The preferred method of payment is through an Auto ACH where TASC Initiates submission of yourfee payment via ACH. To start this process: (1) choose which ACH process you want below, (2) verify your Expected Date of Receipt (EDR), and (3) provide ourbanklnformation: (1) I 0 TASC ACH (default): TASC Initiates funding payment via ACH on the EDR. 0 Client MyTASC Funding: Client Initiates funding payment via MyTASC on or before the EDR. Note: Under this option, TASC will use your Account and Routing Numbers to post any unpaid funding amounts that are one (1) business day past the due date. Also, addltlonal annual feewlll apply if ACH is not elected ($10.00 per payroll). - (2) Expected Date of Receipt EDR is the date that TASC will pull an Auto ACH from your designated account and apply the payroll contributions to your (EDR): - participants account(s). This may or may not be the same date as the participant's payroll data. The EDR date is the payroll contribution schedule Indicated above for each payroll cycle. (3) : Bank Information: ❑ Use same ACH info from Part 4 of this Application ❑ Use different ACH information as per below: Financial Institution Name: State: Bank Routing Number IS digits): Checking Account #: ADMIN ONLY: TASC GiveBacl<- Special Instructions: -- Page 11 Empoyerinitial '. ���� '41VASC TU9913-010117 ---- -- Page 13 Employer Initial 'All TC -3923-010117 A� n' CERTIFICATE OF LIABILITY INSURANCE .-T�2017" " THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policyles) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions ofthe policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER M3 Insurance Solutions, Inc. 828 John Nolen Drive Madison WI 53713 mari NAME: LIPHONE Arc No Ecit 6 082 882 826 ac, rvo: EMAILLDDRESS: cath .'ehnBm3ins.com ER 'FOR CUSFOMER IO p: TOTAA-1 Y INSURE US) AFFORDING COVE MG E NAICW 10/1/2017 INSURED INSURERA: Travelers Pro ert & Casualtv 25674 Total Administrative Se TVlces Corporation 2302 Inte rnatronal Lane INSURERB:The Travelers Indemnitv Co. of Corin INSURER C: Travelers Indemnitv of America 25666 Madison WI 53704 INSURER D CLAIMS MADE OCCUR INSURER E INSURER F MED EXP (Any one person) $10,000 COVERAGES CERTIFICATE NUMBER: 1378362495 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WTH RESPECT TO WHICH THIS CERTI FICATE MAY BE I SET ED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREI N IS SUBJECT TO ALL THE TERM S, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOSNV MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE Attn: Purchasing Department POLICY NUMBER POLICY MM MWDDNYY) LIMITS C GENEML LIABILITY Y Y H630SX888588COF19 10/1/2017 10/1/2018 EACH OCCURRENCE $1,000,000 PREMISE (Ea occurrence) $500,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR MED EXP (Any one person) $10,000 PERSONAL&ADVINJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGRE A PODUTS-OMPOPA$2,000,000 POJCYGRm PLIMIT LPC $ A AUTOMOBILE LIABILITY BASA114687 10/1/2017 10/1/2018 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) X ANY AUTO BOD LY ICU RY(Re r person) $ ALL OWN ED AUTOS BOD LY ICU RY(Re r accident) $ SCHER ULED AUTOS HIRED AUTOS PROPERTY DAMAGE $ (Per accident) $ NONOWNED AUTOS $ A X BMBRELIA LIAB N OCCUR 1UNnm LW88588TIL17 10/1/2017 10/1/2018 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 EXCESSLIAB CIAIMSMADE DEDUCTIBLE $ $ X RETENTION $10,000 B B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YEN HEVB8017C97617 HDTEEDB8022C68SI7 10/1/2017 10/1/2017 10/1/2018 10/1/2018 X WC bLATU- OTH- TORY LIMITS ER ANYPROPRIETOR/PARTNEDEXECUTIVE❑ EL EACH ACCIDENT $500,000 OFFICERMIEMBER EXCLUDED9 NJA EL DISEASE -EA EMPLOYEE $500,000 (MandanoWin NH) I!y describe under I SCRIPTION OF OPERATIONS below ELDISEASE -POIJCYLIMIT $500,000 OESCRIPTIDN OF OPERA IIS/LOCALONS/VEHICLES(Adman ACORD 101, Addi Tonal Remarks Schedule, if more space is required) Umbrella is Excess of Employers Liability, Auto and General Liability. Certificate holder, its officers, agents, and employees are additional insureds with respect to General Liability per attached CG D417 0112. Notice of Cancellation provided per policy provisions. CERTIFICATE HOLDER CANCELLATION © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED City of Santa Ana IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Purchasing Department 20 Civic Center Plaza Santa Ana CA 92701 AOTHOREED REPRESENTALVE © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD ab, V/ AqA'7~w� ACORDV CERTIFICATE OF LIABILITY INSURANCE �� DarE lmm/oo YYvI 10/10/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE RTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER M3 Insurance Solutions, Inc. 828 John Nolen Drive CONTACT NAME: Lisa Acker PHONE FAX talc Ne Ext 608-288-2827 ac No: 608-273-1725 E-MAIL Do Ess: lisa.acker@m3ins.com INS URERS1 AFFORDING COVERAGE NAICN 101112019 EACH OCCURRENCE 51.000,000 INSURER A: Charter Oaks Fire Company 4COMMERCII CLAIMS -MADE OCCUR INSURED Total Administrative Services Corporation 2302 International Lane INSURERS: Travelers Property & Casualty 25674 INSURER C: JNSURER D: Madison, VVI 53704 INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: 833325211 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADD L D! SUBR POLICY EFF D POLICY NUMBER MM/OD/YYYY POLICY EXP MM/DD/YYYY LIMITS A L GENERAL LIABILITY Y Y H5305A885588COF17 10/1/2018 101112019 EACH OCCURRENCE 51.000,000 4COMMERCII CLAIMS -MADE OCCUR 'DAMAGE TO RENTED PREMISES Ea occurrence $ 500,000 MED EXP (Any one person) $ 10.000 PERSONAL 8 ADV INJURY $1.000000 GEHL AGGREGATE LIMIT APPLIES PER:. GENERAL AGGREGATE $2,000,000 X POLICY PRO- JECT D LOG PRODUCTS - COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY ' BA5A1146137 I 10/12018 10/1/2019 COMBINED SINGLE LIMIT $1,000,000 Ea accident) ANY AUTO BODILY INJURY(Per person) $ Ix OWNED SCHEOULEU AUTOS ONLY AUTOS BODILY INJURY Per accident 5 ( iHIRED X l NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTYDAMAGE $ Per accitlenl $ B X UMBRELLA LIAB X OCCUR CUP6J097403 10/1/2018 10/112019 EACH OCCURRENCE $1,000000 EXCESS LIAB CLAIMS -MADE '_AGGREGATE S 1,000.000 BED I X I RETENTION$ 100M _ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N UBAJB91951 10112018 10/1/2019 X PER OTH- STATUTE ER ANYPROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMSER EXCLUDED? NIA EL EACH ACCIDENT $500,000 _ _-._-- — (Mandatory in NH) E. L. DISEASE -EA EMPLOYEE $500.000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT 1 $500,000 DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Umbrella is Excess of Employers Liability, Auto and General Liability. Certificate holder, its officers, agents, and employees are additional insureds with respect to General Liability per attached CG D417 0112. Notice of Cancellation provided per policy provisions. City of Santa Ana Attn: Purchasing Department 20 Civic Center Plaza Santa Ana CA 92701 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ISI^ All rinhfs ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TECHNOLOGY XTEND ENDORSEMENT This endorsement modifies Insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE PART GENERAL DESCRIPTION OF COVERAGE — This endorsement broadens coverage However, coverage for any injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to this Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement. The following listing Is a general cover- age description only Limitations and exclusions may apply to these coverages. Read all the provisions of this en- dorsement and the rest of your policy carefully to determine nghls, duties, and what Is and is not covered A. Reasonable Force Property Damage — Ex- ception To Expected Or Intended Injury Ex- clusion B. Non -Owned Watercraft Less Than 75 Feet C. Aircraft Chartered With Pilot D. Damage To Premises Rented To You E. Increased Supplementary Payments F. Who Is An Insured — Employees And Volun- teer Workers — First Aid G. Who Is An Insured — Employees — Supervi- sory Positions H. Who Is An Insured — Newly Acquired Or Formed Organizations I. Blanket Additional Insured — Owners, Manag- ers Or Lessors Of Premises J. Blanket Additional Insured — Lessors Of Leased Equipment PROVISIONS A. REASONABLE FORCE PROPERTY DAMAGE— EXCEPTION TO EXPECTED OR INTENDED IN- JURY EXCLUSION The following replaces Exclusion a., Expected Or Intended Injury, in Paragraph 2., of SECTION I — COVERAGES — COVERAGE A BODILY IN- JURY AND PROPERTY DAMAGE LIABILITY: a. Expected Or Intended Injury Or Damage "Bodily injury" or "property damage" expected or intended from the standpoint of the insured This exclusion does not apply to "bodily injury" or "property damage" resulting from the use of rea- sonable force to protect any person or property K. Blanket Additional Insured — Persons Or Or- ganizations For Your Ongoing Operations As Required By Written Contract Or Agreement L. Blanket Additional Insured — Broad Form Vendors M. Who Is An Insured — Unnamed Subsidiaries N. Who Is An Insured — Liability For Conduct Of Unnamed Partnerships Or Joint Ventures 0. Medical Payments — Increased Limits P. Contractual Liability — Railroads Q. Knowledge And Notice Of Occurrence Or Of- fense R. Unintentional Omission S. Blanket Waiver Of Subrogation B. NON -OWNED WATERCRAFT LESS THAN 75 FEET The following replaces Paragraph (2) of Exclusion g., Aircraft, Auto Or Watercraft, in Paragraph 2. of SECTION I — COVERAGES — COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY (2) A watercraft you do not own that is (a) Less than 75 feet long, and (b) Not being used to carry any person or property for a charge. C. AIRCRAFT CHARTERED WITH PILOT The following is added to Exclusion g., Aircraft, Auto Or Watercraft, In Paragraph 2. of SECTION CG D4 17 01 12 02012 The Travelers Indemnity Company All rights reserved Page 1 of 6 Includes copyrighted material of Insurance services Office, Inc with its permission 001239 COMMERCIAL GENERAL LIABILITY I — COVERAGES — COVERAGE A BODILY IN- JURY AND PROPERTY DAMAGE LIABILITY This exclusion does not apply to an aircraft that is 4. The following replaces Paragraph a. of the definition of "Insured contract" in the DEFINI- TIONS Section (a) Chartered with a pilot to any Insured. (b) Not owned by any Insured, and (c) Not being used to carry any person or prop- erty for a charge 6 D. DAMAGE TO PREMISES RENTED TO YOU 1. The first paragraph of the exceptions in Ex- clusion j., Damage To Property, In Para- graph 2. of SECTION I — COVERAGES — COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY is deleted 2. The following replaces the last paragraph of Paragraph 2., Exclusions, of SECTION I — COVERAGES — COVERAGE A BODILY IN- JURY AND PROPERTY DAMAGE LIABIL- ITY Exclusions c., g. and In., and Paragraphs (1), (3) and (4) of Exclusion j., do not apply to "premises damage" Exclusion f.(1)(a) does not apply to "premises damage" caused by fire unless Exclusion If. of Section I — Cover- age A — Bodily Injury And Property Damage Liability is replaced by another endorsement to this Coverage Part that has Exclusion - All Pollution Injury Or Damage or Total Pollution Exclusion in Its title. A separate limit Of Insur- ance applies to "premises damage" as de- scribed in Paragraph 6. of Section III — Limits Of Insurance 3. The following replaces Paragraph 6. of SEC- TION III — LIMITS OF INSURANCE 6. Subject to S. above, the Damage To Premises Rented To You Limit is the most we will pay under Coverage A for damages because of "premises damage" to any one premises The Damage To Premises Rented To You Limit will be. a. The amount shown for the Damage To Premises Rented To You Limit on the Declarations of this Coverage Part, or b. $300,000 if no amount is shown for the Damage To Premises Rented To You Limit on the Declarations of this Coverage Part a. A contract for a lease of premises. How- ever, that portion of the contract for a lease of premises that Indemnifies any person or organization for "premises damage" is not an "Insured contract', The following is added to the DEFINITIONS Section "Premises damage" means "property dam- age" to a. Any premises while rented to you or tem- porarily occupied by you with permission of the owner, or b. The contents of any premises while such premises is rented to you, If you rent such premises for a period of seven or fewer consecutive days 6. The following replaces Paragraph 4.b.(1)(b) of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: (b) That Is insurance for "premises damage": or 7. Paragraph 4.b.(1)(c) of SECTION IV — COMMERCIAL GENERAL LIABILITY CON- DITIONS is deleted E. INCREASED SUPPLEMENTARY PAYMENTS 1. The following replaces Paragraph 1.b. of SUPPLEMENTARY PAYMENTS — COVER- AGES A AND B of SECTION I — COVER- AGES. b. Up to $2,500 for cost of ball bonds re- quired because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies We do not have to fur- nish these bonds 2. The following replaces Paragraph 1.d, of SUPPLEMENTARY PAYMENTS — COVER- AGES A AND B of SECTION I — COVER- AGES d. All reasonable expenses Incurred by the Insured at our request to assist us In the Investigation or defense of the claim or "suit", including actual loss of earnings up to $500 a day because of time off from work. Page 2 of 6 C 2012 The Travelers Indemnify Company All rights reserved CG D4 17 01 12 Includes copyrighted material of Insurance Services Office, Inc with its permission WHO IS AN INSURED — EMPLOYEES AND VOLUNTEER WORKERS — FIRST AID 1. The following is added to the definition of "oc- currence" In the DEFINITIONS Section. Unless you are in the business or occupation of providing professional health care services, "occurrence" also means an act or omission committed by any of your "employees" or "volunteer workers", other than an employed or volunteer doctor, in providing or failing to provide first aid or "Good Samaritan services' to a person. 2. The following is added to Paragraph 2.a.(1) of SECTION II — WHO IS AN INSURED, Unless you are in the business or occupation of providing professional health care services, Paragraphs (1 )(a), (b), (c) and (d) above do not apply to "bodily injury" arising out of pro- viding or falling to provide first aid or "Good Samaritan services' by any of your "employ- ees" or "volunteer workers', other than an employed or volunteer doctor Any of your "employees" or "volunteer workers" providing or failing to provide first aid or "Good Samari- tan services' during their work hours for you will be deemed to be acting within the scope of their employment by you or performing du- ties related to the conduct of your business 3. The following is added to Paragraph 5. of SECTION III — LIMITS OF INSURANCE For the purposes of determining the applica- ble Each Occurrence Limit, all related acts or omissions committed by any of your "employ- ees' or "volunteer workers" in providing or failing to provide first aid or "Good Samaritan services' to any one person will be deemed to be one "occurrence". 4. The following Is added to the DEFINITIONS Section "Good Samaritan services" means any emer- gency medical services for which no compen- sation is demanded or received G. WHO IS AN INSURED — EMPLOYEES — SU- PERVISORY POSITIONS The following is added to Paragraph 2.a.(1) of SECTION II —WHO IS AN INSURED: Paragraphs (1)(a), (b) and (c) above do not apply to "bodily Injury" or "personal Injury" to a co - "employee" in the course of the co -"employee's" employment by you arising out of work by any of COMMERCIAL GENERAL LIABILITY your "employees' who hold a supervisory posi- tion H. WHO IS AN INSURED — NEWLY ACQUIRED OR FORMED ORGANIZATIONS The following replaces Paragraph 4. of SECTION II — WHO IS AN INSURED of the Commercial General Liability Coverage Form, and Paragraph 3. of SECTION II —WHO IS AN INSURED of the Global Companion Commercial General Liability Coverage Form, to the extent such coverage forms are part of your policy. Any organization you newly acquire or form, other than a partnership or joint venture, of which you are the sole owner or in which you maintain the majority ownership interest, will qualify as a Named Insured If there Is no other Insurance which provides similar coverage to that organiza- tion However a. Coverage under this provision Is afforded only (1) Until the 180th day after you acquire or form the organization or the end of the policy period, whichever is earlier, if you do not report such organization In writing to us within 180 days after you acquire or form It: or (2) Until the end of the policy period, when that date is later than 180 days after you acquire or form such organization, if you report such organization In writing to us within 180 days after you acquire or form It. and we agree in writing that it will con- tinue to be a Named Insured until the end of the policy period, b. Coverage A does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the organization, and c. Coverage B does not apply to "personal in- jury" or "advertising injury" arising out of an offense committed before you acquired or formed the organization I. BLANKET ADDITIONAL INSURED — OWNERS, MANAGERS OR LESSORS OF PREMISES The following is added to SECTION 11 — WHO IS ANINSURED Any person or organization that is a premises owner, manager or lessor Is an insured, but only with respect to liability arising out of the owner- ship, maintenance or use of that part of any prem- ises leased to you The Insurance provided to such premises owner, manager or lessor does not apply to: CG D4 17 01 12 (fig 2012 The Travelers Indemnity Company All rights reserved Page 3 of 6 Includes copyrighted material of Insurance Services Office, Inc with its permission 001240 COMMERCIAL GENERAL LIABILITY a. Any "bodily Injury" or "property damage" caused by an "occurrence" that takes place, or "personal Injury" or "advertising Injury" caused by an offense that is committed, after you cease to be a tenant In that premises, or b. Structural alterations, new construction or demolition operations performed by or on be- half of such premises owner, manager or les- sor J. BLANKET ADDITIONAL INSURED — LESSORS OF LEASED EQUIPMENT The following is added to SECTION II — WHO IS ANINSURED Any person or organization that is an equipment lessor Is an insured, but only with respect to liabil- ity for "bodily injury", "property damage", "per- sonal injury" or "advertising injury" caused, in whole or in part, by your acts or ornlssions In the maintenance, operation or use by you of equip- ment leased to you by such equipment lessor The insurance provided to such equipment lessor does not apply to any "bodily Injury" or "property damage" caused by an "occurrence" that takes place, or "personal injury" or "advertising injury" caused by an offense that is committed, after the equipment lease expires K. BLANKET ADDITIONAL INSURED — PERSONS OR ORGANIZATIONS FOR YOUR ONGOING OPERATIONS AS REQUIRED BY WRITTEN CONTRACT OR AGREEMENT The following Is added to SECTION II — WHO IS ANINSURED Any person or organization that is riot otherwise an Insured under this Coverage Part and that you have agreed in a written contract or agreement to include as an additional Insured on this Coverage Part Is an Insured, but only with respect to liability for "bodily injury" or "property damage" that a. Is caused by an "occurrence" that takes place after you have signed and executed that con- tract or agreement, and b. Is caused, in whole or in part, by your acts or omissions In the performance of your ongoing operations to which that contract or agree- ment applies or the acts or omissions of any person or organization performing such op- erations on your behalf The limits of Insurance provided to such insured will be the limits which you agreed to provide In the written contract or agreement, or the limits shown In the Declarations, whichever are less L. BLANKET ADDITIONAL INSURED — BROAD FORM VENDORS The following Is added to SECTION II — WHO IS ANINSURED Any person or organization that is a vendor and that you have agreed in a written contract or agreement to Include as an additional insured on this Coverage Part Is an Insured, but only with re- spect to liability for "bodily Injury" or "property damage" that a. Is caused by an 'occurrence" that takes place after you have signed and executed that con- tract or agreement; and b. Arises out of "your products" which are dis- tributed or sold In the regular course of such vendor's business The Insurance provided to such vendor Is subject to the following provisions a. The limits of Insurance provided to such ven- dor will be the limits which you agreed to pro- vide in the written contract or agreement, or the limits shown in the Declarations. which- ever are less b. The insurance provided to such vendor does not apply to: (1) Any express warranty not authorized by you, (2) Any change In "your products" made by such vendor, (3) Repackaging, unless unpacked solely for the purpose of inspection, demonstration, testing, or the substitution of parts under Instructions from the manufacturer, and then repackaged in the original container, (4) Any failure to make such Inspections, ad- justments, tests or servicing as vendors agree to perform or normally undertake to perform in the regular course of business, it) connection with the distribution or sale of "your products", (5) Demonstration, installation, servicing or repair operations, except such operations performed at such vendor's premises In connection with the sale of "your prod- ucts"; or (6) "Your products" which, after distribution or sale by you, have been labeled or re- labeled or used as a container, part or in- gredient of any other thing or substance by or on behalf of such vendor Page 4 of 6 0 2012 The Travelers Indemnity Company All rights reserved CG D4 17 01 12 Includes copyrighted material of Insurance services Office, Inc with its permission Coverage under this provision does not apply to a. Any person or organization from whom you have acquired "your products", or any ingre- dient, part or container entering into, accom- panying or containing such products, or b. Any vendor for which coverage as an addi- tional insured specifically is scheduled by en- dorsement M. WHO IS AN INSURED — UNNAMED SUBSIDI- ARIES The following is added to SECTION II — WHO IS ANINSURED Any of your subsidiaries, other than a partnership or joint venture, that is not shown as a Named In- sured in the Declarations is a Named Insured if a. You maintain an ownership interest of more than 50% in such subsidiary on the first day of the policy period, and b. Such subsidiary is not an insured under simi- lar other insurance No such subsidiary is an insured for "bodily injury" or "property damage" that occurred, or "personal injury" or "advertising injury" caused by an of- fense committed a. Before you maintained an ownership interest of more than 50% in such subsidiary, or b. After the date, If any, during the policy period that you no longer maintain an ownership in- terest of more than 50% in such subsidiary N. WHO IS AN INSURED — LIABILITY FOR CON- DUCT OF UNNAMED PARTNERSHIPS OR JOINT VENTURES The following replaces the last paragraph of SECTION II — WHO IS AN INSURED: No person or organization is an insured with re- spect to the conduct of any current or past part- nership or joint venture that is not shown as a Named Insured in the Declarations This para- graph does not apply to any such partnership or joint venture that otherwise qualifies as an in- sured under Section II — Who Is An Insured O. MEDICAL PAYMENTS — INCREASED LIMITS The following replaces Paragraph 7. of SECTION III—LIMITS OF INSURANCE 7. Subject to 5. above. the Medical Expense Limit is the most we will pay under Coverage C for all medical expenses because of "bodily Injury" sustained by any one person, and will be the higher of: (a) $10,000, or COMMERCIAL GENERAL LIABILITY (b) The amount shown on the Declarations of this Coverage Part for Medical Expense Limit P. CONTRACTUAL LIABILITY—RAILROADS 1. The following replaces Paragraph c. of the definition of "insured contract" in the DEFINI- TIONS Section c. Any easement or license agreement, 2. Paragraph f.(1) of the definition of "insured contract' in the DEFINITIONS Section is de- leted Q. KNOWLEDGE AND NOTICE OF OCCUR- RENCE OR OFFENSE The following is added to Paragraph 2., Duties In The Event of Occurrence, Offense, Claim or Suit, of SECTION IV — COMMERCIAL GEN- ERAL LIABILITY CONDITIONS e. The following provisions apply to Paragraph a, above, but only for the purposes of the in- surance provided under this Coverage Part to you or any insured listed in Paragraph 1. or 2. of Section II —Who Is An Insured (1) Notice to us of such 'occurrence" or of- fense must be given as soon as practica. ble only after the 'occurrence" or offense is known to you (if you are an Individual), any of your partners or members who is an Individual (If you are a partnership or joint venture), any of your managers who is an individual (if you are a limited liability company), any of your trustees who is an individual (if you are a trust), any of your "executive officers" or directors (if you are an organization other than a partnership, joint venture, limited liability company or trust) or any "employee" authorized by you to give notice of an 'occurrence" or offense. (2) If you are a partnership, joint venture, lim- ited liability company or trust, and none of your partners, joint venture members, managers or trustees are individuals, no- tice to us of such 'occurrence" or offense must be given as soon as practicable only after the "occurrence" or offense is known by (a) Any individual who is. (i) A partner or member of any part- nership or joint venture; (it) A manager of any limited liability company, CO D4 17 01 12 @ 2012 The Travelers Indemnity Company All rights reserved Page 5 of 6 Includes copyrighted material of Insurance Services Office, Inc with its permission 001241 COMMERCIAL GENERAL LIABILITY (iii) A trustee of any trust. or (iv) An executive officer or director of any other organization, that is your partner, joint venture member, manager or trustee, or (b) Any "employee" authorized by such partnership, joint venture, limited li- ability company, trust or other organi- zation to give notice of an "occur- rence" or offense (3) Notice to us of such "occurrence" or of- fense will be deemed to be given as soon as practicable if it is given in good faith as soon as practicable to your workers' compensation Insurer This applies only if you subsequently give notice to us of the "occurrence" or offense as soon as prac- ticable after any of the persons described in Paragraphs e. (1) or (2) above discov- ers that the "occurrence" or offense may result in sums to which the Insurance provided under this Coverage Part may apply. However, if this policy Includes an endorse- ment that provides limited coverage for "bod- ily injury" or "property damage" or pollution costs arising out of a discharge, release or escape of "pollutants" which contains a re- quirement that the discharge, release or es- cape of "pollutants" must be reported to us within a specific number of days after Its abrupt commencement, this Paragraph e. does not affect that requirement R. UNINTENTIONAL OMISSION The following is added to Paragraph 6., Repre- sentations, of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS The unintentional omission of, or unintentional er- ror in, any Information provided by you which we relied upon In Issuing this policy will not prejudice your rights under this Insurance However, this provision does not affect our right to collect addi- tional premium or to exercise our rights of cancel- lation or nonrenewal in accordance with applica- ble insurance laws or regulations S. BLANKET WAIVER OF SUBROGATION The following is added to Paragraph 8., Transfer Of Rights Of Recovery Against Others To Us, of SECTION IV — COMMERCIAL GENERAL LI- ABILITY CONDITIONS: If the insured has agreed in a contract or agree- ment to waive that insured's right of recovery against any person or organization, we waive our right of recovery against such person or organiza- tion, but only for payments we make because of a. "Bodily Injury" or "property damage" caused by an "occurrence" that takes place, or b. "Personal Injury" or "advertising injury" caused by an offense that is committed, subsequent to the execution of the contract or agreement. Page 6 of 6 r02012 The Travelers Indemnity Company All rights reserved CG D4 17 01 12 Includes copyrighted material of Insurance Services Office, Inc with its permission Ejhjubmmz!tjhofe! EBUF!)NN0EE0ZZZZ* Bohjf! DFSUJGJDBUF!PG!MJBCJMJUZ!JOTVSBODF cz!Bohjf! UIJT!DFSUJGJDBUF!JT!JTTVFE!BT!B!NBUUFS!PG!JOGPSNBUJPO!POMZ!BOE!DPOGFST!OP!SJHIUT!VQPO!UIF!DFSUJGJDBUF!IPMEFS/!UIJT Bdfwfep! DFSUJGJDBUF!EPFT!OPU!BGGJSNBUJWFMZ!PS!OFHBUJWFMZ!BNFOE-!FYUFOE!PS!BMUFS!UIF!DPWFSBHF!BGGPSEFE!CZ!UIF!QPMJDJFT Bdfwfe CFMPX/!!UIJT!DFSUJGJDBUF!PG!JOTVSBODF!EPFT!OPU!DPOTUJUVUF!B!DPOUSBDU!CFUXFFO!UIF!JTTVJOH!JOTVSFS)T*-!BVUIPSJ\[FE Ebuf;! SFQSFTFOUBUJWF!PS!QSPEVDFS-!BOE!UIF!DFSUJGJDBUF!IPMEFS/ 3133/17/25! 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