HomeMy WebLinkAboutDocumentation_Regular_Tab 08_05/13/2010 VILLAGE OF TEQUESTA
AGENDA ITEM TRANSMITTAL FORM
1. VILLAGE COUNCIL ME ETING:
Meeting Date: Meeting Type: Regular Ordinance #: Click here to enter text.
05/13/2010
Consent Agenda: No Resolution #: Click here to enter text.
Originating Department: Human Resources
2. AGENDA ITEM TITLE: (Wording form the SUBJECT l ine of your staff report
Premium Conversion Plan Summary Plan Description, Plan Document and Adoption Agreement
3. BUDGET / FINANCIAL IMPACT:
Account #: Click here to enter text. Amount of this item: Click here to enter text.
Current Budgeted Amount Available: Amount Remaining after item:
Click here to enter text.
Budget Transfer Required: Choose an Appropriate Fund Balance: Choose an item.
item.
4. EXECUTIVE SUMMARY OF MAJOR ISSUES: (This is a snap shot description of the agenda item)
The Premium Conversion Plan is a program that permits eligible employees to use tax -free
income to pay premiums for qualified benefits programs under Section 125 of the Internal
Revenue Code. The Village is required by Federal law to have an executed Plan Document
on file and as efforts to locate an original executed document have been unsuccessful, an
updated plan document has being prepared for the Council's approval, to ensure compliance.
5. APPROVALS:
Dept. Head: Finance DirectoF r pproved
No Financial Impact
Attorney: (for legal sufficiency) Yes No ❑
Village Manager:
s
• SUBMIT FOR COUNCIL DISCUSSION: Routing Sheet Process
1. Send ALL completed forms to
• APPROVE ITEM: ❑ Finance for review ONE WEEK prior
to agenda items due into Clerk's
❑ Office.
• DENY ITEM: 2. Finance sends Routing Sheet to
Form amended 08/26/08 Clerk by deadline.
3. Clerk formulates agenda and sends
to Manager for review / approval.
Village of T ecluesta
Memo
To: Michael R Couzzo, Jr., Village Manager
From: Merlene Reid, HR Director 40
Date: April 12, 2010
Re: Premium Conversion Plan — Village of Tequesta
The Finance Department requested HR's assistance in locating the Village's
Premium Conversion Plan document as they only had in their possession, a partially
executed document dated April 1, 1994 (See Exhibit 1).
The Premium Conversion Plan is a program that permits eligible employees to
use tax -free income to pay premiums for qualified benefits programs under
Section 125 of the Internal Revenue Code. The Village is required by Federal law
-to have an executed Plan Document on file and as efforts to locate an original
executed document have been unsuccessful, an updated Plan Document, along
with an Adoption Agreement (Exhibit 2) has being prepared for Council's
approval, with the assistance of the Village's Brokers, to ensure compliance.
The qualified programs currently identified by the Village of Tequesta, include:
• Medical Insurance
• Dental Insurance
• Vision Insurance, and
• Certain Aflac programs which include Dread Disease, Hospital
Indemnity, Hospital Sickness, Critical Illness and Intensive Care
Insurance.
HR is requesting that the Council approve the Plan Document, along with the
Adoption Agreement and will have a representative on hand at the May 13 Council
meeting to assist with addressing any questions that they may have on this matter.
Reid, Merlene
From: Keith W. Davis [keith @corbettandwhite.com]
Sent: Thursday, April 22, 2010 4:46 PM
To: Reid, Merlene
Subject: Premium conversion plan
Merlene:
Reviewed and approved for form and sufficiency.
Sent from my iPhone
1
VILLAGE OF TEOVESTA TEL :407 -575 -6239 Peb 10 95 16:56 NO-001 P.01
EXHIBIT 1
p!rMiUiVI COM MICN PLC
APRUCA M
Name of y e
F.m to r• Village of Teque Florida
p
Address: 357 Teu esta DrjXe -- - Tequesta Florida 33469
Street City State Zip
Primary Contact: Beal C. Ka sc a velis, Finance Director
Number of Eligible Employees: 36
Desired Effective Date: Apr 1, 1994
Desired Enrollment Method: (Circle One)
Automatic Mandatory l Voluntary
Signature of Authorized Representative:
Thomas G. Bradford, V3. -.g(.- Iris Tager
TERMS
Fees are payabic in advance and should accompany this application. Checks should be wade
payable to Acordis of South Florida, Inc. The fee structure is as follows:
QpiiotW womane Consulting
$300.00 $100/year
The completed application and fees should be seat to Aeordlw of South Florida, Inc., $ot
South Flagler Drive, Suite 604, West Pahn Batch, FL 33401. Attn: Susan & Vasileff. For
more infotsmation, please call Susan E. Vtullett (407) $38401.
Once the initial fee is received, implementation materials and forma will be provided. Acordia
CO><porate offers guidance only and accepts no mponsibility for the content of the plan
documents or the administrat of the plan.
Poet -It "' brand Tax transmittal memo 71M # of Pow ►
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t' =xsLE _a$NSFI j PLAN
BA's! L, - RE _ S KT=
A ICLE ESL
I INTRODUCTION ............. ............................... 1
1 .01 The Plan ............. ..........'.................... 1
1 .02 Applicability ....... ............................... A
1 .03 Plan Status ......... .66.11 .......................... 1
YY DEFINITIONS .............. ............................... 1
2.01 "Account. ........... ............................... I .
2.02 "Adoption Agreement" 1
2.03 " Affiliate" .......• . ............................... 1
1
2.04 "Cods" .............. ...............................
2 0.7 "Compensation* ...... •.....•.,.••••..•.......•...... 1
2.06 ('Effective Dater' .... .....66 .............e *......... 1
2.07 "Eioaployee" .......... ..........a9...040444..........
2.08 " Employer" .........6 ......6 ...................6.... 1
2 .09 "Benefit Dollars" ... ............................... 2
(a) "Employer Non - Discretionary
Benefit Dollars" 2
(b) "Employer Discretionary Benefit
Dollars" ........ 2
(c) "Participant After -Tax Benefit
Dollar$" .... ............................... 2
2.10 •Highly Compensated Employee" 2
2.11 "Highly Compensated Participant" 2
2.12 "xey Employee" ...... ..............0................ 2
2.13 " Participant" ....... ............................... 2
2.14 "Plan" ..........4116.. ...11. .................6..6.... 2
2 .15 "Plan Year" ......... . .............................. 7
III ADOPTION OF PLAN ......... . .............................. 3
IVPARTICIPATION ............ ............................... 3
4.01 Eligibility for EM loyees 3
4.02 Cessation of participation 3
4.03 Application to Participate 3
V PLAN FINANCING AND BENEFIT ELECTIONS 3
5.0 Employer Non -- Disc r et ionary
B enefit Dollars ..... ............................... 3
5.02 Benefit Dollars Other Than Employer
Non - Discretionary Benefit Dollars 3
5.03 Elections and Consents 4
S.04 Changes by the Uployer ............................ 4
5.09 Irrevocability of Election by the
Participant During the Plan Year 4
5.06 Automatic Termination of Election
and Consent ......... 0 49#0406##* .... S
5.07 Forfeitures 00 S
......... .................
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VILLAGE OF TIEQUESTA TEL:407 -575 -6239 Feb 10 95 16:57 No.001 P.03
VI oPTIONAL SBNEFITS ........ .•.•..••....•..•............... S
6.01 Benefit Options ..... ............................... S
(a) Health Coverage ............................... 5
(b) Dental Coverage ............................ 5
(e) Long -Term Disability Coverage 6
(d) short -`term Disability Coverage 6
(s) Supplemental Short -Term
Disability Coverage ..• ........................ 6
(if) Employes Croup -Term Life
I nsurance ...... ......• ........................ 6
(q) Dependent Group -Tern Life
I nsurance ...... ............................... 7
(h) Accidental Death and ]Dismemberment
Insurance .r.•. .,...,9..••...r•9.... +000.0• +.+ 7
(i) Dependent Care Expense
P rogram ........ ........................... &... 7
(j) Health Care Expense
Reimbursement Program ...•.........•...••.9•••9 7
(k) Vacation . . 000...9...... 7
(1) Qualified Group Legal Servicer.Plan ........... 8
6.02 Limited Use of participant After -
Tax Benefit Dollars • .....•• +....•.•..••.•••••••.... 8
6.03 Benefits Determination 8
6.04 Cash ................ ............................... $
VII PROHIBITED DISCRIMINATION ............................... g
7,01 Cafeteria Plan
Anti. - Discrimination Ruses 6
7.02 Other Code Anti- Discrimination
R ules ............... ............................... a
VIII ADMINISTRATION OF PLAN ... ............................... 9
8.01 Administration 9
8.02 Powers of Plain Administrator •...... ................ 6
6.03 Actions of Plan Administrator 9
6.04 Claims .............. . . 0 ............................ 9
8.05 Examination of Records ............................. 9
8.06 Reliance an Tables, eto. 9
6.07 Non - discriminatory Exercise of
A uthority ........... 0000 ........................... 9
IX AXENDMFOUi'Y' AND TERMINATION OF PLAN 10
X 1923CELLANS00S PROVISIONS ............................... 10
10.01 inforuation to be rurnished 10
10.02 Limitation of Rights •..........•••.•...•..... 10
10.03 Governing Lair . ............................... 10
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VILLAGE OF TEGUESTA TEL =407 -575 -6239 Feb 10 95 16:58 No.001 F.04
ARTICLE Y INTROaTiCTU
1.01 The Plan The purpose of this Plan is to provide
Participants with a choice between the receipt of cash
compensation and certain nontaxable benefits available through
various employee benefit plans maintained by the Employer.
7..02 Ann i abilit' The provisions of this Plan are
applicable only to Chose eligible, persons who are Employees of
the Employer on or after the date the Employer adopt* this Plan.
1.03 $la,Q_Status This Plan is intended to qualify as a
cafeteria plan under Section 125 of the Internal Revenue code of
1954.
AKlO$ I t • DSFIN TT Nfi
2.01 "A ccount " means the account or accounts as established
for the Participant fox the purpose of accounting for
contributions allocated to and benefits paid to or on behalf of a
Participant.
2.02 " AdWtion Agreement means the document executed by an
adopting Employer.
2.03 " Aff{ 1in s " meant (a) any corporation which is a member
of the same controlled group of corporations (within the meaning
of Srction 414(b) of the Code) as is the Zmployer, (b) any other
trade or business (whether or not incorporated) controlling,
controlled by, or under common control (within the meaning of
Section 414(c) of the Code.) with the Employer and (c) any other
organization which is a member of an affiliated service group
(within the meaninq of section 414(m) of the Code) with the
Employer.
2 .04 "faQS" means the Internal. Revenue Code of 1954, as
amended, and any successor thereto.
2.09 " C9=Snsation " means those components of compensation
selected by the Sbployer on the Adoption Agreement which are paid
to a Participant by the Employer during the plan Year.
2.06 " Effec fy Me " means the date on which the Plan
became effective as to any Employer as specified in the Adoption
Agreement.
2.07 "Emnlu " means any person who is employed by an
Employer and classified as an employee for purposes of coverage
under one or more of the benefit plans maintained by the
Employer.
2.08 " Mover " meant the adopting employer hereunder.
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VILLAGE OF TEQUESTA TEL :407- 575 -6239 Feb 10 95 16:59 No.001 P.05
2.09 " Bpntt , 20 " means the amounts credited to the
Account of a participant under this Plan, and which shall consist
of the following:
(a) " lp,plover, MM-Discretionary gene it R211ars means
the ammount of Employer contributions credited to the
Account of a Participant which shall be used by the
Employer to provide benefits under the employee benefit
plans selected by the Employer in the Adoption
Agreement.
(b) N Emnloyer D rjorMtjgj3ArY jilkne9ft Dollars means the
amount of Employer contributions credited to the
Account of a Participant which may be used by a
Participant to provide benefits under the employee
benef it plans selected by the Employer in the Adoption
Agreement.
(c) " Salar Reduction Benefit be11gZs means the
aiaount of Employer contributions attributable to
reductions in compensation as elected by a Participant,
which shall be credited to the Account of the
Participant.
(d) "Partigipant " means the
amount of contributions made by a Participant which are
not deductible from the pa:rticil nt's taxable income,
and which shall be credited to the Account of the
Participant.
2.I0 " "ghly C moansated ovee means an Employee (a) who
is an officer, ('b) who is a shareholder owning more than 5
percent (5%) of the voting power or value of all classes of stork
of the Employer, or (c) 'a highly compensated employee.
2.11 " Hicthiy QQ egoat Partielpant means a Participant
who is a Highly Compensated Employee or a spouse or dependent
thereof.
2:12 " He,Y. Emxlievee means an Employee who as defined in
section 416 (1) (1) of the Code.
2.13 swans any individual who satisfies the
eligibility requirements of the Plan as set forth in Article 3
and who participates in the Plan.
2.14 "EIJM" means the riexible Benefit Plan as set forth
herein, and as may be amended From time to time.
2 .15 " Pla Year means the twelve (la) month period
designated by the Employer in the Adoption Agxeeaent.
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VILLAGE OF TEQUESTA _ TEL :407- 575 -6239 Feb 10 95 16 =59 Na.001 P.06
ARTICLE SIX - ADOPTION OF PLAN
An Employer may adopt this Plan by the execution of an
Adoption Agreement.
ARTI IV - U=CIPATTOR
4.01 Rlig h� ty ram EmRjgvg Bach person who is an
Employee shall become a Participant in this Plan an the date
designated by the Employer in the adoption Agreement.
4 . 0 2 Cessation 0 9, 9Af, -i n & s n . A p articipant will cease
to be a participant as of the earlier of (a) the date on which
the Plan terminates, or (b) the last day on which he ceases to be
covered under one or more of the employee benefits plans, which
provide the benefits described in section 1.1.
4.03 Appilcation to Participats. Each Employee who becomes
eligible to participate in this .Plan shall, Complete the fora$ and
provide the data As required by the lioployer ae a condition to
participate. The forois and data shall be delivered to the
Employer at least thirty (30) days prior to the first day of an
Zoployee's participation in the plan.
AMCLE V - ELAN A'YN]1NCING AND BEt�F�gT te�irrrn e
5.01 EnIgVer. JRIgcretio"Ary 9e1mef i t - Dot s s For each
Plan Year, an Employer which has selected Em ploy er Non- -
Discretionary Benefit Dollars on the Adoption Agreement shall
inform each Participant of the amount of Employer Non -
Discretionary Benefit Dollars which shall be applied by the
Employer to provide employee benefits under the employee benefit
plans selected by the Employer in the Adoption Agreement.
5 0
Ba-�.t l i .Dollars For each Plan Year, the Uployer will determine
the amount of all other Benefit Dollars which Can be credited to
the Account of each Participant, and shall inf each
Participant in writing of the amount before, the beginning of the
Plan Year. The amount will consist of any one or more of the
tollowinq, as selected by the IMployer in the Adoption Agreement:
(a) Employer Diagr _tinnsa w Ii A..14M prior to
the beginning of eaoh Plan Year, and ftployer which has
selected Employer Discretionary Benefit Dollars on the
Adoption Agreement may, at its sole discretion, also
Credit Employ Discretionary Ben Dollars to the
Account of each Participant.
(b) a antit QW11ars An Employer
shall credit to the Account Of each participant who has
3 -
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VILLAGE OF TEGUEST14 TEL:407- 575 -6239 Feb 10 T 95 17:00 No 001�F.07
elected to reduce the amount of his Compensation for
the plan Year the amount of the reduction. An election
may only be made pursuant to a written agreement
between the Participant and his Employer, which shall
specify the amount of the reduction in Compensation
which is to be credited to the Account of the
Participant.
(C) FartiCipan de r - Tax AenetiC Dallj" An
Employer shall credit to the Account of each
Participant the amount of contributions made to the
Plan by the Participant as Participant After -Tax
Benefit Dollars. For this purpose, the Employer may
withhold contributions from the Compensation of the
Participant provided that the Participant has given
consent therefor.
5.03 ElectiQUe and Conswnts The election required by
Section 5.02(b) and the consent required by Section 5.02(0) must
be submitted to the Employer (a) on or before the last day of the
Plan Year preceding the plan year in which the election or
consent is to become effective, in the case of an Employee who
has been a Participant in the Plan, and (b) prior to the first
day upon which a new election is to become effective in the erica
of Participant who becomes entitled to change or revoke an
election pursuant to section 5.05 of the Plan or prior to the
first day, upon which a new election or Consent in to become
effective in the case of an Employee who is a new Participant in
the Plan. if an Employee fails to submit an election form
required by Section 5.02 (b), his Compensation for the Phan Year
will not be reduced.
5.04 s hangg* bX the Em lg= If the Employer determines
the plan may fail to satisfy any non - discrimination requirements
imposed by the Code, the Employer shall take any action as it
deems appropriate to assure compliance with such requirement, to
Include, without limitation, a modification of elections by
Highly Compensated Participants with or without their perm as ion.
5. rrrMXS aAhijjjv of Election by the arrtfginant bur Nn
Mgg .plan Y ear . Elections made udder Section 5.02(b) of the plan
shall be irrevocable by the Participant during the Plan Year,
except in the event of a change in family status. A change in
family status includes marriage, divorce, death of a spouse or
child., birth or adoption of a child, termination of employment of
a spouse and any ether event that the Employer determines will
permit a change or revocation of an election during a Plan Year
under regulations and rulings of the Internal Revenue Service.
Any new election under this Section 5.03 shall be effective at
the time an -the Employer shall prescribe, but not earlier than
the first pay period beginning after the election form is
completed and returned to the Employer.
4
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VILLAGE OF TEQUESTA r TEL :407- 575 -6239 Feb 10 ^ 95 17 =01 No .001 P.0$
5.06 kutoIDptic Termination of ElepJ;,jgn and Consent
Elections and consents made under this Plan shall automatically
terainate on the date on which the Participant ceases to be a
Participant in the plan.
5.07 Forfeitures Benefit Dollard which are credited to the
Account of a participant except for those attributable to
Participant After -Tax benefit Dollars on the last day of the Plan
Year will be forfeited by the participant. Participant After -Tax
Benefit Dollars will remain in the Account for use by the
Participant in succeeding'Pla" Years.
ARTICLE vi - 0EU2 a A E.- F
6.01 Be0e91 208 Except as provided in Section 6. 02,
for each plan Year, each Participant shall have the option to
apply the Benef it Dollars credited to his Account in order to
provide the following benefits, if the enplcyee benefits plans
under which the benefits would be provided have been selected by
the Staployer in the Adoption Agres%ent:
(a) Health Cnveraae 'o the extent a Participant
elects, any or all of the Benefit Dollars credited to
his Account shall be used to pay the Partieipantes
share of the cost of coverage under the MVloyer's
health benefit plan. If there is a change in the cost
at the type of coverage selected by a Participant,. the
Participant's selection shall automatically be adjusted
to reflect the change. A Participant will not be
Permitted to change or revoke an election during a plan
Year because of a change in the cost of coverage.
(b) aentai Coverage To the extent a. Participant
elects, any or all of the Benefit Dollars credited to
his Account.shall be used to pay the Participantos
share of the cost of coverage under the Employer "s
dental benefit plan. If there is a change in the cost
Of the. type of coverage elected by the Participant, the
Participant's election Shall automatically be adjusted
to reflect the change. A Participant will not ba
Permitted to change or revoke an election during a Plan
Year because of a change in the cost of Coverage.
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VILLAGE OF TEQUESTA TEL :407 -575 -6239 Feb 10 95 17 :02 No.001 P.09
(c) L no -Teerm DiggbilitY Gpygraare To the extent &
Participant elects, any or all of the Benefit Dollars
credited to leis .Account shall be used to pay the
Participant's share of the cost of coverage under the
Employer's long - -terra disability plan. if there is a
change in the cost of the type of coverage selected by
the Participant, the Participant's election shall
automatically be adjusted to reflect the charge. A
Participant will not be permitted to change or revoke
an election during a Plan Year because of a change in
the cost of coverage.
(d) $hart -Term Qiaabillty Coy XM TO the extent a
Participant elects, any or all of the Benefit Dollars
credited to his Account shall be used to pay the
Participant's share of the cost of coverage under the
Employer's short -term disability plan. If there is a
change in the cost of the type of coverage selected by
the participant, the participant's election shall
automatically be adjusted to reflect the change. A
Participant will not be permitted to change or revoke
an election during a Plan Year because of a Change in
the cost of coverage.
(e) SU2919mental Short-TRIM QL§apility CoverAa . To
the extent a participant elects, an or all of the
Benefit Dollars credited to his Account shall be used
to acquire supplemental short -term disability coverage
designed to supplement the Employer's short -term
disability plan.. It there is a change in the Cost of
the type of coverage selected by the Participant, the
Participant's election shall automatically be adjusted
to reflect the change. A Participant will not be
Permitted to change or revoke an election during a Plan
Year because of a change in the coast of coverage.
(f) Emolovee GrauD -Term Life- ZnsuraA To the extent
a participant elects, any or all of the Benefit Dollars
credited to his Account shall be used (1) to pay the
Participant's share of the cost of coverage under the
Rmployer's group -term life insurance plan or (2) to
acquire additional life insurance coverage under the
Employer's group -term life insurance plan, or (3) bath.
If there is a change in the cost of the type of
coverage selected by the Participant, the participant's
election shall automatically be adjusted to reflect the
change. A PArticl ant will not be permitted to' change
or revoke an election during a plan Year because of a
change in the Cost of coverage.
• d -
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VILLAGE OF TEGUESTA TEL:407 -575 -6239 Feb 10 95 17:02 No.001 F•10
(g) 12eng den - cr2 p -'re_ rm i!e inmL; . To the
extent a Participant elects, any or all of the Benefit
Dollars credited to his Account shall be. used either
(1) to pay the Participant's share at the' cost the
coverage under the Employer's group -tarm life insurance
plan or (2) to acquire coverage under the Employer's
dependent group -term life insurance plan, or (1) both.
If there is a chang in the cost of the type of
coverage selected by the Participant, the Participant's
election :shall automatically be a d justed to reflect the
change. A Partialppant:.will not be permitted to change
or revoke an election during a Plan Year because of a
change in the coat of coverage.
(h) AS Oeath and bJM%9 J =nt Tnsurance To
the extent a Participant elects, any or all at the
Benefit Dollars credited to his Account shall be used
to pay th Participant's share of the cost of coverage
under the Employer's accidental death and dismemberment
insurance plan. If there is a change in the cost of
the type of coverage selected by the participant, the
Participant's election shall automatically be adjusted
to reflect the change. A Participant will not be
permitted to change or revoke an election during a Plan
Year because of a change in the cost of coverage.
(i) Dependant Q&a. &Mense , . To the extent a
Participant elects, any or all of the Benefit: Dollars
credited to his Account shall be used for reimbursement
of enoployment- related dependent oars expenses incurred
by the Participant.
(j)
Health gars Expense beimbur§%M gent ,RX9 r m To the
extent a Participant elects, any or all of the Benefit
D credited to h Account shall be used for.
reimbursement of health care expenses not covered by
the Employer's health or dental benefit plan or any
other plan or policy providing health and dental
benefits to the Participant: and his dependents.
(k) Yagation To the extent a Participant elects, any
Or all of the Benefit Dollars credited to his Account
shall be used for the acquisition of up to five (.B)
Paid vacation days in addition to the number of regular
paid vacation days Which the Participant receives for
t he Plan Year.
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VILLAGE OF TEQUESTA TEL:407- 575 -6239 Feb 10 95 17:03 N0.001 P.11
(1) oua�? ! t +d, r,2gp, Zi cr Rarvices Plan - ( *Z)cpires
December 31, 1987) . To the exte a paxti,cLP&nt
elects, any yr all of the Depe Dollars credited to
his Account shall be used to pay the Participant?$
share of the cost of coverage under the Employer"*
qualified group legal services plan. It there is a
change in the type of the cost of coverage under the
Empioyerfs group legal services plant, the Participant's
election shall automatically be adjusted to reflect the
change. A Participant will not be permitted to change
or revoke an election during a Plan Ysaii because of a
change in the cost of coverage.
6.02 .
A Participant shall have the option to apply those Benefit
Dollars credited to his Account which are attributable to
Part icipant After -Tax Benefit Dollars onl to provide acci dent
and health coverage, dental coverage, employee group -terw life
insurance dependent care and qualified group legal services.
6.03 penefitg oe� taxid3Rat,,iae The benefits which
Participants have elected to receive under the Plan will not be
provided by this Plan but by the employee benefit plans sponsored
by the ftployor, as in effect from time to time.
6.04 h . For any Plan Year, in lieu of any of the
benefits described in Section 6.01, A Participant ma elect to
receive in amsh all of the mounts which are or could have been
credited to his Account as Employer Discretionary Benefit
Dollars, salary Reduction Benefit Dollars, or Participant After -
Tax Benefit Dollars, but may not elect to receive in cash any
amount credited to his Account as Employer Non- Discretionary
Benefit Dollars.
As ICY E V1 _ pA10HIBITED D .iM Nl►TTON
7.01 Cat9teria Plan anti- Discrimination Rules in
accordance with section 125 of the Code, the Plan shall not
discriminate in favor of Highly compensated Employees or highly
compensated Participants.
7.01 - . The benefits
available under this Plan area, in all instances, provided by
separator employee benefit plans for which the Code may impose
specific non - discrimination requirements. Each benefit option as
described in Article v2 shall be governed by any applicable non -
discrieainati.vn requirement imposed by the Code in order to avoid
discrimination in favor of Highly compensated Participants
highly compensated Employees.
8
fsT /7T'.J L77Q(il CCq MC 117A1 TI.I O 1'"111L1fA17"IMfIAI Of`.Cm OCC T - 7T — I'NM
rOJD10bGtl: ill
VILLAGE OF TEQUESTA TEL:407 - 575 -6239 ' Feb 10 95 17:04 No.001 P.12
AR_ T��LE VYT - ADM1=6TRAT ON Ar. PLAN.
8.01 84tginistration The Plan administrator shall be the
Employer. The Plan administrator may delegate its powers and
authority under the Plan and may designate any person ar persons
to exercise these powers and authority on its tbehalf. In the
delegation of powers and authority, the Plan administrator may
limit the authority of the recipient of they delegated powers and
the authority to redelegate..those powers and authority to - another
person or persons.
8.02 J Q X=1% of 'plan , 4mJnistr&J;12; The Plan administrator
shall have All. powers which are necessary to administer the plan,
including but not limited to the interpretation of the provisions
of the Plan, the establishment of accounting methods - for the
Plan, the establishment of rules and the prescription of any -
forms necessary or desirable for the administration of the plan.
8.03 AQtigns o!'•Plan_Administr� r . All determinations,
interpretat ons,•rules and decisions of the Plan administrator
shall. be conclusive and binding upon all parsons having or
claiming to have an interest or right under the Plan.
8.04 ClAin6. Any claim which arises under any employee
benefit plan maintained by the Employer shall not be subject to
review under thi,S Plan. The Plan administrator "s author ty under
Section 8.02 shall not extend to any matter as to which ate
administrator under any employe* benefit plan maintained by .the
Employer is empowered to wake determinations and all claims will
be processed in accordance with the claims procedures of that
plan.
8.05 zZom The Plan administrator will
maka available to each Part cipant any records under the plan
that pertain to him, for examination at reasonable times during
normal business hours.
8006 Iteliaace on Tables, ate In administering the Plan,
the Plan administrator will be entitled to the extent par�littad
by law to rely conclusively on all tables, valuations,
certificates, opinions rind reports which are furnished by, or in
accordance with the instructions of, the admini strators of the
above- refer*r ploy*es benefit plans, or by accountants,
counsel or other experts employed or engaged by the plan
administrator.
8.07 Whe nev er, in
the administration of the Plan, an discretion
Plan Administrator is required, the Plan Administrator
exorcise its authority in a non - discriminatory manger. It shall
be the principal duty of the Plan Administrator to se* that the
Plan is carried out in accordance with its terms for the
exclusive benefit-of persons entitled to participate in the Plan.
• 9 w
1
Vi'd 1U101
. 1 . r V Y. V . .. � ... . r . v . _ _ r . n - •- - - - - - -
axluz Ix - 7►M _ 1 m �1►� TmommT20N of P s
The Employer reserves the right to aaend or terminate the
Plan in whole or in part at any time by a duly adopted resolution
of they Employer's board of directors or other governing body.
ARTICI�X - MIIMLAKEOtis�$RU11�S
10.01 Iaformation to Furrnishga Participants shall
provide the Employer and Plan Administrator with any informati
and evidence, and shall sign all documents, as may reasonably be
requested from time to time for the purpose of the administration
of the Plan.
10.02 Limit tipa of gjahtp Nothing in this Plan nor any
sloction made hereunder shall give a Participant or his
benefioiary the right to any benefit payments under this Plan, a
Participant's rights being limited to the right to elect the
optional benefits described in Article Vx. coverage and the
right to benefit payments are governed by the applicable employee
benefit plan of the Employer. the establishment of this Plan
shall not be construed to give any Employee a right to be
continued in the employ of the Em or as interfering with
the right of the Employer to tsrroinate the employment of any
Employee at any time.
10.03 rning l" . This plan and all rights hereunder.
shall be governed by and construed according to the laws of the
state Which the Employer has designated in the adoption
Agreement, except to the extent these laws are preempted by the
laws of the United States of America.
IN WITNESS WHEREOF, the Employer has Caused this P lan to be
executed on this day of
Sys
Title :
A
Hy:
Title:
(SEAL)
10
EXHIBIT 2
Premium Conversion Plan
Summary Plan Description and Plan Document
Introduction
The Premium Conversion Plan is a program that permits eligible employees to use tax -free
income, rather than after -tax income, to pay premiums for certain Qualified Benefit Programs.
The purpose is to reduce the actual cost of participating in the Qualified Benefit Programs. The
Premium Conversion Plan consists of this Summary Plan Description and Plan Document in
addition to the accompanying Adoption Agreement, which is incorporated by reference into this
document.
Authori ty
The Premium Conversion Plan is authorized and governed by Section 125 of the Internal
Revenue Code of 1986, as amended, and other related Sections of the Internal Revenue Code.
Definitions
a. Adoption Agreement - A document containing specific information about the Premium
Conversion Plan as it applies to the employer and its employees. The Adoption Agreement
along with this Summary Plan Description and Plan Document make up the Premium
Conversion Plan.
b. Employee - A person engaged in the conduct of business for the Employer; excluding sole
proprietors, partners, and 2% or greater shareholders in an S- corporation, independent
contractors and other classes of individuals specified in the Adoption Agreement such as
members of collective bargaining units, if any.
c. Employer - The entity or entities defined in the Adoption Agreement.
d. Highly Compensated Employee - Any Employee defined as such by Section 414(q) of the
Internal Revenue Code.
e. Key Employee - Any Employee defined as such by Section 416(i)(1) of the Internal Revenue
Code
f. Open Enrollment - A period of time during which an eligible employee may select benefits
for the coming Plan Year.
g. Participant - An employee paying for Qualified Benefit Programs with tax -free income under
the Section 125 Premium Conversion Plan.
h. Payroll Deduction - The process of withholding premiums or employee contributions for
Qualified Benefit Programs from Employees' paychecks. Payroll Deduction cannot occur if
the Employee is not actively receiving income from the Employer that would otherwise be
taxable.
i. Plan - The Premium Conversion Plan as defined by this document and the Adoption
Agreement incorporated into the Plan by reference.
j. Plan Administrator - The entity that makes decisions regarding the operation of the Premium
Conversion Plan. The Plan Administrator is the Employer.
k. Plan Sponsor - The entity that makes the Premium Conversion Plan available to employees
The Plan Sponsor is the Employer.
1. Plan Year - The Plan Year is a fixed period of time, usually twelve months, during which
employees may not change benefits unless a qualifying event occurs. The Plan Year is
defined in the Adoption Agreement. See "Changing Benefits" for more information about
Qualifying Events.
m. (Qualified Benefit Programs - Employer - sponsored insurance policies and/or self - insurance
programs that Section 125 allows employees to fund with tax -free income.
n. Qualifying Event - An event which results in a change in eligibility in a Qualified Benefit
Plan or an external plan, as defined by Section 125 of the Internal Revenue Code, that creates
an opportunity for employees to change participation in the Premium Conversion Plan and
the underlying Qualified Benefit Programs. See the section on Qualifying Events for more
information.
o. Tax-free - Exempt from federal income taxes, FICA taxes (Medicare and Social Security),
and state and local income taxes where Rermissible
ElisibUity
Employees eligible to participate in any or all of the Qualified Benefit Programs and pay their
share of qualified insurance premiums via payroll deduction are eligible to participate in the
Premium Conversion Plan.
Qualified Benefit Pronrams
The Qualified Benefit Programs are the insurance plans selected by the employer in the Adoption
Agreement. The premiums for each Qualified Benefit Program will be paid with tax -free income
up to the lesser of the actual premium or the maximum allowed by the Internal Revenue Code.
2
Qualified Benefit Programs are those listed in the Adoption Agreement and may include any or
all of the following:
• Employer - provided accident and sickness coverage such as medical, dental, vision,
accidental death and dismemberment, disability, and certain cancer, dread disease, hospital
indemnity, hospital sickness, critical illness and intensive care policies under Sections 105
and 106 of the Internal Revenue Code.
• Employee contributions to a Health Savings Account (HSA) authorized under Section 223 of
the Internal Revenue Code.
• Employee group term life insurance in amounts up to $50,000 of coverage, including any
employer- provided coverage under Section 79 of the Internal Revenue Code. (Dependent
life insurance is not eligible.)
This plan does not offer any benefit that defers the receipt of compensation. Participants may not
use one Plan Year's contributions to purchase benefits in a subsequent Plan Year, or to carryover
unused benefits from year to year.
The Qualified Benefit Programs included in the Premium Conversion Plan are listed in the
Adoption Agreement. The benefits, rules and limitations of the Qualified Benefit Program(s) are
described in separate insurance policies, certificates, or other appropriate documents. Copies of
such documents can be obtained from the Employer. This document is not intended to provide
specific information about the Qualified Benefit Programs.
Except as expressly provided herein, nothing contained in the Plan shall be construed to alter the
terms of the Qualified Benefit Programs or policies of the vendors of those programs or to
provide any benefits other than those provided by the Qualified Insurance Plans and the policies
of the vendor.
The Employer may add, change or cancel Qualified Benefit Programs at any time without prior
notice.
Enrolling in Benefits, Chaceing Benefits, Canceling Benefits
Section 125 of the Internal Revenue Code allows employees to elect to participate in Qualified
Benefit Programs and change or cancel this election only
• During the open enrollment immediately preceding each Plan Year; or
• When an employee experiences a Qualifying Event.
The employer may establish a reasonable deadline for submission of requests during the annual
open enrollment period. Benefit changes requested during the Open Enrollment Period will take
effect on the first day of the coming Plan Year.
If a benefit change is requested at a time other than the Open Enrollment Period, the employee
must have experienced one or more of the Qualifying Events. The requested change must be
submitted within 30 days of the Qualifying Event and must be consistent with the event. Benefit
3
changes must take effect after such choices are communicated to the employer using a properly
completed form, on the date specified by the employer in the Adoption Agreement. Changes in
benefits may never be retroactive.
Oualifvine Events
The Qualifying Events are as follows:
• Marriage or Divorce;
• Gaining a Dependent due to Birth, Attaining Minimum Age, Court Order, Decree or
Judgement;
• Losing a Dependent due to Death, Attaining Maximum Age, Court Order, Decree or
Judgement;
• Becoming eligible for Medicare or Medicaid, or losing eligibility for Medicare or Medicaid;
• Beginning or Ending an Unpaid Leave of Absence, including a leave under the Family
Medical Leave Act (FLMA);
• Changes in eligibility due to changes in employment of the employee, spouse or dependents;
• Open enrollment for spouse's benefit plan(s);
• Special enrollment rights under the Health Insurance Portability and Accountability Act
(HIPAA) following the loss of other health coverage or if the person becomes the spouse or
dependent of an employee through birth, marriage, adoption or placement for adoption; or
• Other Qualifying Events permitted by Section 125, as amended, if any.
The Qualifying Event must result in the employee, spouse or dependent becoming eligible or
losing eligibility for insurance coverage.
Requested changes in Qualified Benefit Programs must be "on account of the event and
consistent with the event.
Ceasing Participation
Employees will cease participation in the Premium Conversion Plan when:
• Participation in the Qualified Benefit Programs ceases;
• The employee ceases paying the premiums via payroll deduction;
• Eligibility to participate in the Premium Conversion Plan ceases; or
• The Premium Conversion Plan terminates.
No action is required of the employee.
Ceasing participation in the Premium Conversion Plan does not prevent participation in the
Qualified Benefit Programs as permitted under the Family Medical Leave Act (FMLA) or the
Consolidated Omnibus Budget Reconciliation Act (COBRA).
4
Plan Fundine
Employee tax -free premium contributions for Qualified Benefit Programs will be treated as
employer funds for the purposes of the Premium Conversion Plan. The employee's taxable salary
is reduced by the amount of the qualified premiums and the employer uses this money to pay the
premiums. This is the mechanism that allows the employee to avoid paying taxes on the
premiums. Participants may not contribute more than 100% the total compensation derived from
the employer. If the employee elects to waive participation in one or more of the Qualified
Benefit Plans in accordance with the applicable rules stated herein, the employee may retain the
corresponding portion of his/her income (cash). The employer may also contribute toward the
cost of the Qualified Benefit Programs, but such contribution is not required.
Nondiscrimination Rules
The Premium Conversion Plan shall not discriminate in favor of Highly Compensated or Key
employees in its benefits or its operation.
No more than 25% of the aggregate (total) tax -free premiums paid under the Premium
Conversion Plan may be paid by Key Employees.
The Employer may amend the Plan, terminate the Plan, or modify the participation levels of
Highly Compensated or Key employees to bring the Plan into compliance with the
nondiscrimination rules.
Plan Administration
The Employer serves in the role of both Plan Sponsor and Plan Administrator. The Employer
may establish reasonable rules and procedures affecting the operation of the plan as long as such
rules are consistent with all laws and regulations and are applied consistently.
The Employer may change the Premium Conversion Plan at any time, including administrative
rules and procedures, without prior notice.
The Employer may suspend or terminate the Premium Conversion Plan at any time, without
prior notice.
The Employer may amend the Premium Conversion Plan retroactively to enable the Plan to
qualify under Section 125 of the Internal Revenue Code. No such amendment shall deprive any
Participant of any benefit to which he or she is entitled under this Plan with respect to previously
paid premiums for Qualified Benefit Programs, except as provided under the nondiscrimination
rules.
Neither the Employer nor any agent of the Employer or the Plan represent or guarantee that the
Plan will qualify under the Internal Revenue Code at any time, nor is the Employer obligated to
amend any aspect of the Plan which results in failure to meet the requirements of the Internal
Revenue Code.
5
Specific Plan Information
Information specific to the Premium Conversion Plan provided by the Employer is included in
the Adoption Agreement that is part of this document.
Other Important Information
Participation in the Premium Conversion Plan does not create an employment contract between
the Employer and the Employee, nor does the Premium Conversion Plan serve as an inducement
or consideration for the employment of any Employee or Participant. The Premium Conversion
Plan does not give the Employee or Participant the right to be retained by the Employer, nor does
it interfere with the right of the Employer to discharge the Employee of Participant at any time.
The Employee or Participant, upon dismissal or voluntary termination shall have no right or
interest in the Plan unless such right is expressly stated by the Plan.
Any Employee may request a copy of the Premium Conversion Plan.
No benefit under the Premium Conversion Plan may be assigned to another party.
Indemnification of Persons Acting on Behalf of the Employer
The Employer agrees to indemnify and reimburse, to the fullest extent permitted by law, its
current and former governing board (if any), management and/or other employees acting for the
Employer, for any and all expenses, liabilities or losses arising out of any act or omission relating
to the performance of services for or for the management and administration of the Plan.
Headings
The headings in this Plan have been included for convenience or reference only and are to be
ignored in any construction of the provisions herein.
Gender and Number
In the construction of the Plan, the masculine shall include the feminine or neuter, and the
singular shall include the plural and vice versa in all cases where such meanings would be
appropriate.
Governing Law
This Plan shall be construed, enforced and administered according to the laws of the state
specified in the Adoption Agreement.
6
IN WITNE S WHEREOF, the Employer has caused this Plan to be executed on this
day of , 20
By:
Printed Name: /A 5- c J ATK / NS
Title: M ROOK
ATTEST: ,o QF ....
oQ`Q OR.gj�s��
By: 1), dW(.Q�- SSEAL
Title: INCORPOWED..'
7
PREMIUM CONVERSION PLAN
ADOPTION AGREEMENT
Plan Sponsor: Village of Tequesta
Federal Tax ID Number: 59- 6044081
Village of Tequesta hereby adopts the Village of Tequesta Premium Conversion Plan (Plan) on
March 9, 2010. This Premium Conversion Plan Adoption Agreement along with the Summary
Plan Description and Plan Document are intended to satisfy the 'written plan' requirement of
Section 125 of the Internal Revenue Code.
This Adoption Agreement represents an amendment or restatement of the Village of Tequesta
Premium Conversion Plan sponsored by Village of Tequesta with an original effective date of
April 1, 2004.
Effective Date
The Original Effective Date of the Plan is April 1, 2004. The Effective Date of this Summary
Plan Description and Plan Document is April 1, 2010.
Plan Number
The Plan Number is 502.
Plan Year
The Plan Year shall be twelve -month periods beginning each October 1.
Participation Rules
Eligible employees must enroll to participate in the Premium Conversion Plan. A properly
completed form must be submitted to the Plan Sponsor within the designated time periods.
Participation begins with participation in the medical insurance plan following the submission to
the Plan Sponsor of a properly completed form, if such form is required by the Plan Sponsor.
Additional participation rules are included in the Summary Plan Description and Plan Document.
Qualified Benefit Programs
Qualified Benefit Programs shall include:
• Medical Insurance
• Dental Insurance
• Vision Insurance
• Cancer /Dread Disease Insurance
• Hospital Indemnity
• Hospital Sickness
• Critical Illness
• Intensive Care
Agent for Service of Legal Process
Pat Watkins, Mayor
Village of tequesta
345 Tequesta Drive
Tequesta, FL 33469
561 -575 -6200
Governing Law
This Plan shall be construed, enforced and administered according to the laws of the State of
Florida.
Signature of Authorized Representative of Village of Tequesta
PATRI aA 5 • IZA-rK rtis
Typed or printed name of Authorized Representative.
N AvD R.
Title of Authorized Representative.
,5/1312.0 to
Date of Signature