HomeMy WebLinkAboutDocumentation_Regular_Tab 08_09/09/2010 � �� �� VILLAGE OF TEQUESTA
AGENDA ITEM TRANSMITTAL FORM
1. VILLAGE COUNCIL MEETING:
Meeting Date: Meeting Type: Regular Ordinance #: C!'sc� ��r� tr �r�t��� t���.
09/09/2010
Consent Agenda: No Resolution #: �Eic� ��r� t� �r�ter t�x�.
Originating Department: Human Resources
2. AGENDA ITEM TITLE: (Wording form the SUBJECT line of your staff report)
Council Consideration and Approval of the request to adopt a Flexible Spending Account program and
authorizing the Village Manager to execute the Plan documents.
3. BUDGET / FINANCIAL IMPACT:
Account #: �fick h�r� t� et�i��� ����. Amount of this item: �lick ��r� tc� �r�t�r t�xt.
Current Budgeted Amount Available: Amount Remaining after item:
Gl�c� h�re ta ���t�r �ex�.
Budget Transfer Required: ��a�as� ara Appropriate Fund Balance: Choc�se an it�r��.
itee�.
4. EXECUTIVE SUMMARY OF MAJOR ISSUES: (This is a snap shot description of the agenda item)
The Flexible Spending Account is a program that allows employees to realize relief in respect of health and
dependent care expenses that they anticipate over a plan year. This program allows participants to set
aside a portion of his/her earnings to pay for qualified medical and dependent care. The monies deducted
from the employee's pay for this purpose is not subject to payroll taxes, thus lowering the employee's
amount of total taxable income, as well as the Village's share of payroll taxes. There is no administrative
expense to the Villa e as The Gehrin Group will be underwritin the emplo er's costs.
5. APPROVALS:
�`" ,
,�,, �
Dept. Head: � Finance Director: Approved
No Financial Impact
Attorney: (for legal sufficiency) �J��✓ �,l� � Yes [� No ❑
Village Manager: �T�
Routing Sheet Process
• SUBMIT FOR COUNCIL DISCUSSION: � 1. Send ALL completed forms to
Finance for review ONE WEEK prior
• APPROVE ITEM: ❑ to agenda items due into Clerk's
❑ Office.
• DENY ITEM: 2. Finance sends Routing Sheet to
Clerk by deadline.
Form amended 08/26/08 3. Clerk formulates agenda and sends
to Manager for review / approval.
• • • • •
Memo
To: Michael R Couzzo, Jr., Village Manager
From: Merlene Reid, HR Director
Date: August 30, 2010
Re: Flexible Spending Account — Village of Tequesta
The Human Resources (HR) Department is recommending the addition of a Flexible
Spending Account (FSA) program to the list of benefits currently offered/facilitated by the
Village. The idea developed at management meeting in late August where it was
recommended to assist employees to get some relief in respect of health and dependent
care expenses that they anticipate over the plan year. There is no administrative
expense to the Villaqe as The GehrinQ Group will be underwriting the employer's costs.
A FSA is a program that permits participants to set aside a pre-determined amount of
his/her earnings deducted in equal installments over a 12 month period, to pay for
qualified health and dependent care expenses not covered by insurance. The monies
deducted from the employee's pay for this purpose is not subject to payroll taxes, thus
lowering the employee's total taxable income and also benefits the Village as its share of
payroll taxes is also reduced. There are however potential risks to both the Village and
the employees as any monies remaining in the employee's accounts at the end of the
plan year goes to the employer while an employee who uses the funds and leaves prior to
the end of the plan year, is not required to reimburse the monies spent. A maximum
contribution amount of $2,500 per employee per year will be se# by the Village.
The most common use of FSA is to pay for medical expenses not paid for by insurance,
including deductibles, copayments, and coinsurance. FSAs are also established to pay
for certain expenses to care for dependents while the employee is at work. While this
most commonly means child care for children under the age of 13, it can also be used for
adult day care for senior citizen dependents such as parents living with the employee.
For the reasons outlined above, HR is requesting that the Council approve the request to
adopt a Flexible Spending Account program and authorize you to execute the Plan
documents. The addition of a FSA to the Village's list of benefits will also require an update to
the Premium Conversion Plan Adoption Agreement which was approved by Council at the
May 13, 2010 meeting, an updated copy of which is also attached.
As is customary, a representative will be on hand at the September 9 th Council meeting to
assist with addressing any questions that the Council members may have on this matter.
Reid, Merlene
From: Keith W. Davis [keith@corbettandwhite.com]
Sent: Wednesday, September 01, 2010 4:23 PM
To: Reid, Merlene
Subject: RE: FLEXIBLE SPENDING ACCOUNT
Merlene:
Approved for form and sufficiency.
Keith W. Davis, Esq.
Corbett and V�'hite, P.A.
"I"�le�honc (�61} 586-7116
Board Certified in City, County and Local Government Law
From: Reid, Merlene [mailto:mreid@tequesta.org]
Sent: Wednesday, September 01, 2010 8:59 AM
To: Forsythe, Jody; Keith W. Davis
Cc: McWilliams, Lori
Subject: FLEXIBLE SPENDING ACCOUNT
Jody,
Original of attached Agenda item has been placed in your box for approval.
Keith,
Please review item for form and sufficiency
Lori,
If approved, the mayor will need to sign 2 copies of the updated Premium Conversion Plan Adoption Agreement. The 2
FSA plan documents will be executed at a later date.
Merlene
Merlene Reid, SPHR
Human Resources Director
Village of Tequesta
345 Tequesta Drive
Tequesta, FL 33469-3062
Tel: (561J 768-0415
Fax: (561 J 768-0697
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1
Village of Tequesta
Health Care Flexible Spending Account
Plan Document
Plan Sponsor(s):
Village of Tequesta
FEIN: 59-6044081
lntroduction
The Village of Tequesta has established this Health Care Flexible Spending Account Plan (the
"Plan") to meet the needs of those of its Employees who are Participants in the Plan. The
purpose of this Plan is to provide for the medical protection for certain Participants, their spouses
and their dependents. The Plan will provide benefits only for certain items of inedical, dental and
vision care expenses which are not covered by any other type of employee benefit plan or individual
insurance. The Plan is intended to qualify as a self-insured medical reimbursement plan as
defined in Section 105 of the Internal Revenue Code of 1986, as amended (the "Code"). The
provisions of this Plan are applicable only to those eligible persons who are Employees of the
Employer on or after the Effective Date.
Definitions
a. Adoption Agreement - means the written agreement, executed by the Employer, by which
the Employer adopts this Plan, and the provisions of which are incorporated in this Plan
by reference.
b. AntlClpated Contributions - means the total amount of contributions the participant is
expected to make during the plan year.
c. Appeals Committee - means a committee of at least one (1) individual appointed by the
governing body of the Employer.
d. Coverage Period - means a period of time during the Plan Year in which benefits are
stable due to a regular contribution amount.
e. Effective Date — means October 1, 2010.
£ Eli ig bility Requirement means the requirement(s) for participation set forth in the
Adoption Agreement.
g. Emplo,yer - means the Village of Tequesta.
1
h. Emplovee - means any person who is employed by the Employer for purposes of the
Federal Insurance Contributions Act.
i. Participant - means any Employee who has satisfied the eligibility requirements of the
Plan.
j. Plan Administrator - means the Employer.
k. Plan Year — means October 1, 2010 through September 30, 2011, then twelve month periods
thereafter running from October 1 through the following September 30.
Eli�ibilitv
The Employee may elect to participate in the Plan upon completion of the Eligibility
Requirements specified by the Employer in the Adoption Agreement.
If the Employee elects to participate in the Plan and makes the required contributions, coverage
shall begin on the first day �f the month following the date af the election and �1'iall c���iinue
until the earlier of the last day of the Plan Year or the date coverage ceases.
Each former Participant who is reemployed by the Employer shall again be covered as of the date of
his reemployment as an Eligible Employee.
Each Employee who completes his eligibility requirements but who terminates employment with
the Employer before becoming covered under the Plan sha11 be covered as of the later of (a) the date
of his reemployment as an Eligible Employee or (b) the date as of which he would have become
covered if he had not terminated employment.
Termination of Eli�ibilitv
The eligibility of a Participant will cease upon the earlier of the following:
a. termination of employment;
b. termination of the Plan;
c. amendment to the Plan which terminates coverage of a classification of Employees to
which the Participant belongs;
d. the Participant fails to make the required contributions;
e. the Participant fails to meet the Eligibility Requirements.
If eligibility ceases during a Plan Year, the former Participant may not make a new election for
the remainder of the Plan Year.
2
If the former Participant regains eligibility by again meeting the Eligibility Requirements, the
Employee may elect to participate in the Plan Year next following the date the Eligibility
Requirements were met.
Participation in the Health Care Flexible Spending Account may be continued beyond the
termination of eligibility as permitted under the Family Medical Leave Act (FMLA) or the
Consolidated Omnibus Budget Reconciliation Act (COBRA).
Continuation of Coverage
Participants and qualified dependents may have a right to continue coverage under the provisions
of COBRA through the end of the plan year in which coverage would otherwise cease.
Benefits
The Employer shall establish minimum and maximum annual Employee contributions for each
Plan Yea.r, sui�ject to statut��y liinits. Such minimum ar�� maximum anr�ual Em�loyee
contributions shall be communicated to Employees during the annual enrollment period or upon
eligibility, as applicable.
Not later than ninety (90) days following the date upon which the Participant submits appropriate
claim information, the Employer shall reimburse the Participant up to the Anticipated
Contribution for a given Coverage Period for all amounts incurred by the Participant during the
Plan Year for the prevention, diagnosis, cure, mitigation, or treatment of disease, for the purpose
of affecting any structure or function of the body, or for the treatment and cure of bodily injury
resulting from accidents and for transportation primarily for and essential to medical care for
himself, his spouse and his dependents, as defined in Code Section 105. The Employer shall also
reimburse the Participant for health care expenses for himself, his spouse and his dependents.
The Employer shall not reimburse the Participant for any amounts payable under any other
employee benefit plan or policy or any individual insurance by which the Participant, his spouse,
or dependents are covered. All such reimbursements are must comply with Code Section 213(d),
however, the Employer may restrict or limit such coverage by means of administrative rules
provided such rules are made known to Employees prior to the beginning of each Plan Year or
the date of the Employee's eligibility, as applicable.
3
Benefit Period
The Participant shall be permitted to submit requests for reimbursement of eligible expenses
incurred during the period beginning on the date participation begins within a given Plan Year
and ending on the date participation ends for that Plan Year.
Claims Procedure
A Participant shall make a claim for Benefits by making a request in accordance with the terms
of this Plan Document. Requests must be received within ninety (90) days after the end of the
Plan Year for amounts incurred within the Plan Year.
If a claim is wholly or partially denied, notice of a decision shall be furnished to the Participant
within a reasonable period of time, not to exceed ninety (90) days after receipt of the claim by the
Plan Administrator, unless special circumstances require an extension of time for processing the
claim. If an extension of time is required, written notice of the extension shall be fumished to the
Participant prior to the termination of the initial ninety (90) day period. In no event shall the
extension exceed a period of ninety (90) days from the end of the initial period. The extension
notice shall in�icate thc spccial circumstanccs requiring ar� extension of time and t �z date on
which the Plan Administrator expects to render a decision.
The Plan Administrator shall, upon request, provide a Participant who is denied a claim for
benefits written notice setting forth, in a manner calculated to be understood by the claimant, the
following:
a. a specific reason or reasons for the denial;
b. specific reference to pertinent Plan provisions upon which the denial is based;
c. a description of any additional material or information necessary for the claimant to
perfect the claim and an explanation of why that material or information is necessary;
d. an explanation of the Plan's claim review procedure, as set forth below.
The purpose of the review procedure set forth herein is to provide a procedure by which a
Participant, under the Plan, may have reasonable opportunity to appeal a denial of a claim to the
Appeals Committee for a full and fair review. To accomplish that purpose, the Participant, or his
duly authorized representative may:
a. request review upon written application to the named fiduciary;
b. review pertinent Plan documents; and
c. submit issues and comments in writing.
A Participant or his duly authorized representative shall request a review by filing a written
application for review with the Appeals Committee at any time within sixty (60) days after
receipt of written notice of the denial of his claim.
4
Decision on review of a denied claim shall be made in the following manner:
a. The decision on review shall be made by the Appeals Committee, which may, in its
discretion, hold a hearing on the denied claim; the Appeals Committee shall make its
decision not later than sixty (60) days after the Plan Administrator receives the request for
review, unless special circumstances require extension of time for processing, in which
case a decision shall be rendered as soon as possible, but not later than one hundred
twenty (120) days after receipt of the request for review. If an extension of time for
review is required, written notice of the extension shall be furnished to the Participant
prior to the commencement of the extension.
b. The decision on review shall be in writing and shall include specific reasons for the
decision, written in a manner calculated to be understood by the Participant, and specific
references to the pertinent Plan provisions on which the decision is based.
c. In the event that the decision on review is not furnished within the time period set forth
above, the claim shall be deemed denied on review.
If a dispute arises with resp�ct to any matter under this Plan, ;e P1ar, Administrator may r��ain
from taking any other or further action in connection with the matter involved in the controversy
until the dispute has been resolved.
Funding
Contributions required to pay benefits under this Plan shall consist of contributions by the
Participants under the Employer's Flexible Benefit Plan, and other funds from the general assets
of the Employer, if needed.
Plan Administrator
The Plan Administrator shall be named fiduciary of the Plan and shall have the authority to
manage the operation and administration of the Plan and to adopt such rules and regulations
consistent with the Plan as it shall deem appropriate to administer the Plan. All determinations
by the Plan Administrator shall be conclusive and binding on all Participants, their spouses and
dependents.
Amendment and Termination
This Plan may be amended, suspended or terminated at any time by the goveming body of the
Employer.
5
Miseellaneous
Except where otherwise indicated by the context, any masculine terminology used herein shall
also include the feminine and vice versa, and the definition of any term herein in the singular
shall also include the plural, and vice versa.
This Plan shall not be deemed to constitute a contract between the Employer and any Participant
or Employee or to be consideration or an inducement for the employment of any Participant or
Employee. Nothing contained in this Plan shall be deemed to give any Participant or Employee
the right to be retained in the service of the Employer or to interfere with the right of the
Employer to discharge any Participant or Employee at any time regardless of the effect the
discharge shall have upon him as a Participant of this Plan.
This Plan shall be construed and enforced according to the laws of the state of Florida, except to
the extent those laws are preempted by the laws of the United States of Amenca.
IN WITNESS WHEREOF, the Employer has caused this indenture to be executed on the
day of , 20
By:
Title:
ATTEST:
By:
Ticle:
6
Village of Tequesta
I)epenclent Care Flexible Spending Account
Plan Document
Plan Sponsor(s):
Village of Tequesta
FEIN: 59-6044081
Introduction
The Village of Tequesta has established this Dependent Care Flexible Spending Account Plan
(the "Plan") to meet the needs of those of its Employees who are Participants in the Plan. The
purpose of this Plan is to provide for the work-related custodial dependent care for certain
Participants, their spouses and their dependents. The Plan is intended to qualify as a dependent
care assistance plan as defined in Section 129 of the Intemal Revenue Code of 1986, as amended
(the "Code"). The provisions of this Plan are applicable only to those eligible persons who are
Employees of the Employer on or after the Effective Date.
Defmitions
a. Adoption A�eement - means the written ageement, executed by the Employer, by which
the Employer adopts this Plan, and the provisions of which are incorporated in this Plan by
reference.
b. Appeals Committee - means a committee of at least one (1) individual appointed by the
Board of Directors or other governing body of the Employer.
c. Benefits - means the amounts paid to Participants under the Plan as reimbursements for
Eligible Employment Related Expenses incurred by a Participant.
d. Dependent - means any individual who is a dependent of a Participant within the meaning
of Code Section 152(a).
e. Earned Income - means all income derived from wages, salaries, tips, self-employment and
other employee compensation but does not include any amounts received (i) under the Plan
or any other dependent care assistance program under Code Section 129; or (ii) as a pension
or annuity.
£ Effective Date - means the da#e specified by the Employer in the Adoption Agreement.
g. Eli ig bilitv Requirement - means the requirement(s) far participation set forth in the
Adoption Agreement.
h. Eligible Emplovee - means any individual employed by the Employer for purposes of the
Federal Insurance Contributions Act.
i. Eligible Emplovment Related Expenses - means all Employment Related Expenses incurred
by a Participant which are paid to a person who is not:
• a Dependent of the Participant;
• the Participant's Spouse; or
• a child of the Participant under the age of 19.
j. Emplo� - means the Village of Tequesta.
k. Emplovment Related Expenses - means expenses incurred for Qualifying Services or far the
cost of sending a child of the Participant to a Qualifying Day Care Center.
l. Participant - means any Employee who has satisfied the eligibility requirements under
Article III of the Plan.
m. Plan Administrator - means the Employer.
n. Plan Year - means October 1, 2010 through September 30, 2011, then twelve month periods
thereafter running from Qctober 1 through the following Septe:nber 30.
o. Qualifyin� Dav Care Center - means:
• a day care center which complies with all applicable laws and regulations;
� provides care for more than six individuals, other than individuals who reside at the
day care center; and
� receives a fee payment or grant for providing Qualifying Services for the
individuals.
p. Oualifving Individual - means:
• a Dependent of a Participant who is under the age of 13;
• a Dependent of a Participant who is physically or mentally incapable of caring for
himself; or
• the Spouse of a Participant, if he is physically or mentally incapable of taking care
of himself.
q. Oualifving Services - means Services performed:
• in the home of the Participant; ar
2
• outside the home of the Participant for the care of a Dependent who is under the age
of 13, or for the care of a Qualifying Individual other than a Dependent under the
age of 13, who regularly spends at least eight (8) hours a day in the Participant's
household.
r. Services - means custodial services performed to enable a Participant or Spouse to remain
gainfully employed and which are related to the care of a Qualifying Individual.
s. Spouse - means the spouse of a Participant but shall not include an individual separated or
divorced from a Participant.
t. Student - means an individual who, during each of five calendar months during a Plan Year,
is a full-time student at an educational institution.
Eli ibili
The Employee may elect to participate in the Plan upon completion of the Eligibility
Requirements specified h;� the Employer i� the Adeptio.^. Agreement.
If the Employee elects to participate in the Plan and makes the required contributions, coverage
shall begin on the first day of the month following the date of the election and shall continue
until the earlier of the last day of the Plan Year or the date coverage ceases.
Termination of EliQibilitv
The eligibility of a Participant will cease upon the earlier of the following:
a. termination of employment;
b. termination of the Plan;
c. amendment to the Plan which terminates coverage of a classification of Employees to
which the Participant belongs;
d. the Participant fails to make the required contributions;
e. the Participant fails to meet the Eligibility Requirements.
Benefits
Each Participant in the Plan shall be eligible to receive Benefits under the Plan for all Eligible
Employment Related Expenses incurred by the Participant after he became a Participant in the Plan,
subject however to the limitations herein.
3
Claim for Benefits
Each Participant who desires to receive a Benefit under the Plan for Eligible Employment Related
Expenses incurred for Qualifying Services shall, upon request, submit to the Plan Administrator a
written statement containing the following information:
a. name of the Dependent for whom the Qualifying Services are to be performed;
b. the nature of the Qualifying Services performed for the Participant, the cost for which he
wishes to be reimbursed;
c. the relationship, if any, of the person performing the Qualifying Services to the Participant;
d. if the Qualifying Services are being performed by a child of the Participant, the age of that
child;
e. a statement as to where the Qualifying Services will be performed;
f. if the Qualifying Services are being per in _a day car? center, a statemen_t th2t (al rhe
day care center complies with all applicable laws and regulations; (b) the day care center
provides care for more than six individuals (other than individuals residing at the center);
and (c) the amount of compensation paid to the center;
g. if the Participant is married, a statement of (a) the Spouse's compensation if he is employed,
or (b) if the Participant's Spouse is not employed, a statement that (1) he is incapacitated or
(2) he is a full-time student attending an educational institution and the months during the
year which he will attend the educational institution;
h. the name, address, and the Federal Taa� Identification Number or Social Security Number of
the individual or organization providing the care. The Federal Tax Identification Number or
Social Security Number is not required if the individual or organization is tax-exempt.
If the Participant is eligible to receive Benefits under the Plan, he shall submit a statement to the
Plan Administrator within ninety (90) days after the end of the plan year stating the amount of
Eligible Employment Related Expenses incurred by the Participant. Within thirty (30) days of
receiving the statement, the Plan Administrator shall pay the Participant the Benefits to which he is
entitled under the Plan.
4
Limitations on Beneiits
A Participant may not receive Benefits for Eligible Employment Related Expenses incurred for any
month in excess of his Earned income far that month. If the Participant is married, he may not
receive benefits for any month in excess of the lesser of:
a. his Earned Income for the month; or
b. the Earned Income of his Spouse for that month.
A Spouse who is not employed during any month in which the Participant incurs Eligible
Employment Related Expenses, and is either incapacitated or a Student, shall be deemed to have
Earned Income for that month o£
a. $250, if there is one Qualifying Individual for whom the Participant incurs Eligible
Employment Related Expenses; or
b. $500, if there is more than one Qualifying Individual for whom the Participant incurs
Eligible Employment Related Expenses.
A Participant may not receive Benefits for Eligible Employment Related Expenses for any calendar
year in excess of $5,000.00. A married Participant who files a separate individual tax return may
not receive Benefits for Eligible Employment Related Expenses for any calendar year in excess of
$2,500.00.
�'undin�
Contributions required to pay Benefits under this Plan shall consist of that combination of
contributions by the Employer and the Participant as selected by the Employer under the Employer's
Flexible Benefit Plan.
Plan Administrator
The Plan Administratar shall be the named fiduciary of the Plan and shall have the authority to
manage the operation and administration of the Plan and to adopt such rules and regulations
consistent with the Plan as it shall deem appropriate to administer the Plan. All determinations by
the Plan Administrator shall be binding upon Participants, their spouses and dependents.
5
Claims Procedure
A Participant shall make a claim for Benefits by making a request in accordance with the Claim For
Benefits section.
If a claim is wholly or partially denied, notice of a decision shall be furnished to the Participant
within a reasonable period of time, not to exceed ninety (90) days after receipt of the claim by the
Plan Administrator, unless special circumstances require an extension of time for processing the
claim. If an extension of time is required, written notice of the extension shall be furnished to the
Participant prior to the termination of the initial ninety (90) day period. In no event shall the
extension exceed a period of ninety (90) days from the end of the initial period. The extension
notice shall indicate the special circumstances requiring an extension of time and the date on which
the Plan Administrator expects to render a decision.
The Plan Administrator shall, upon request, provide a Participant who is denied a claim for benefits
written notice setting forth, in a manner calculated to be understood by the claimant, the following:
a. a specific reason or reasons for the denial;
b. specific reference to pertinent Plan provisions upan which the deniai is based;
c. a description of any additional material ar information necessary for the claimant to perfect
the claim and an explanation of why that material or information is necessary;
d. an explanation of the Plan's claim review procedure.
The purpose of the review procedure is to provide a procedure by which a Participant, under the
Plan, may have reasonable opportunity to appeal a denial of a claim to the Appeals Committee for a
full and fair review. To accomplish that purpose, the Participant, or his duly authorized
representative may:
a. request review upon written application to the named fiduciary;
b. review pertinent Plan documents; and
c. submit issues and comments in writing.
6
A Participant or his duly authorized representative shall request a review by filing a written
application for review with the Appeals Committee at any time within sixty (60) days after receipt
of written notice of the denial of the claim.
Decision on review of a denied claim shall be made in the following manner:
a. The decision on review shall be made by the Appeals Committee, which may, at its
discretion, hold a hearing on the denied claim. The Appeals Committee shall make its
decision not later than sixty (60) days after the Plan Administrator receives the request for
review, unless special circumstances require extension of time for processing, in which case
a decision shall be rendered as soon as possible, but not later than one hundred twenty (120)
days after receipt of the request for review. If an extension of time for review is required,
written notice of the extension shall be fumished to the Participant prior to the
commencement of the extension.
b. The decision on review shall be in writing and shall include specific reasons for the
decision, written in a manner calculated to be understood by the Participant, and specific
references to the pertinent Plan provisions on which the decision is based.
c. In the event that the decision �n review is nc�t furnishe�l within the time period set fo�th, the
claim shall be deemed denied on review.
If a dispute arises with respect to any matter under this Plan, the Plan Administrator may refrain
from taking any other or further action in connection with the matter involved in the controversy
until the dispute has been resolved.
flmendment and 'Termination
This Plan may be amended, suspended or terminated at any time by the Board of Directors or
other governing body of the Employer.
7
Niiscellaneous
Except where otherwise indicated by the context, any masculine terminology used herein shall also
include the feminine and vice versa, and the definition of any term herein in the singular shall also
include the plural, and vice versa.
This Plan shall not be deemed to constitute a contract between the Employer and any Participant or
Employee or to be a consideration or an inducement for the employment of any Participant or
Employee. Nothing contained in this Plan shall be deemed to give any Participant or Employee the
right to be retained in the service of the Employer or to interfere with the right of the Employer to
discharge any Participant or Employee at any time regardless of the effect the discharge shall have
upon him as a Participant of this Plan.
This Plan shall be construed and enforced according to the laws of the state which the Employer has
designated in the Adoption Agreement, except to the extent those laws are preempted by the laws of
the United States of America.
IN WITNESS WHEREOF, the Employer has caused this indenture to be executed on the
day of , 20
By:
Title:
ATTEST:
s
T�tie:
s
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 Adoption
Agreement is October 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:
• Medicallnsurance
• DentalInsurance
• Vision Insurance
• Cancer/Dread Disease Insurance
• Hospitallndemnity
• Hospital Sickness
• Critical Illness �
• Intensive Care
• Health Care Flexible Spending Account
• Dependent Care Flexible Spending Account
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
Typed or printed name of Authorized Representative.
Title of Authorized Representative.
Date of Signature