Loading...
REIMBURSEMENT SERVICES AGREEMENT ~JAC ADMINISTRATIVE SERVICES The #1 Provider of Cafeteria Plan Services FEB 272003 CITY CL.\.:T..IV '.'::", . ...":'" '.E' "r L:;\I \ :. .C_.I' :u': ll\:i 'N Dear Plan Administrator: Please find the enclosed: -+- t:xec:;;-copy of the Reimbursement Services Agreement (RSA) to retain for your records. Documentation submitted to our office for your self-administered Flex account. FLEX ONE@ does not require this information and should be retained for your records. Documentation submitted to our office for your premium only plan. FLEX ONE@ does not require this information and should be retained for your records. Documentation for your canceled FSA plan. (These documents should be retained for your files). Salary Redirection Agreements submitted in error. These documents should be retained for the: _Employer _Employee Associate If there are any questions or concerns about the enclosed information, please call our office at (800) 323-5391. FLEX ONE@ Administration AFLAC Administrative ~rvices . FLEX ONP . A Service of American Family Life Assurance Company of Columbus (AFLAC) WorldWIde Headquarters: 1932 Wymlton Road. Columbus, Georgia 31999.800/323-5391 - - - iiiiii iiiiii iiiiii - - -.:t --.:t I'-- C") - - iiiiii - - - - - - - - - - - ~ o o o N ..... ..... ~ N o ..... LO . - - - - .j ~ '- REIMBURSEMENT SERVICES AGREEMENT This Agreement. effective upon execution for the Plan Year, by and between .CITY OF CLEARWATER HUMAN RESOURCES and American Family Life Assurance Company ("AFLAC@") WITNESSETH: WHEREAS, the Employer has adopted a Medical Care Expense Reimbursement ("URM") Plan and/or a Dependent Care Expense Reimbursement ("DOC") Plan for its Employees in conjunction with its Flexible Benefits Plan (collectively referred to as the "Plan" and attached hereto) to be adopted and administered in accordance with Sections 105, 125, and 129 of the Internal Revenue Code of 1986, as amended (the "Code"); and WHEREAS, the Employer will serve as the Plan Administrator; and WHEREAS, the Employer desires that AFLAC, as its agent, furnish reimbursement services within a framework of policies. interpretations, rules, practices and procedures (the "reimbursement practices and procedures") made and established by the Employer in: (i) receiving and processing requests for benefits under the Plan ("Requests") and (ii) disbursing benefit payments from Employer funds (as provided for in Section IIA) for eligible expenses under the flexible spending account provisions of the Plan; (if Self-Pay Option is selected in Section II.A. below, AFLAC shall convey its initial benefit determinations to Employer so the Employer can disburse reimbursement payments for eligible expenses under the Flexible Spending Agreement provisions of the Plan); and WHEREAS, the Employer is to pay all plan benefits owed or established under the Plan to its Participants. and AFLAC is to provide the agreed upon services to the Plan without assuming any such liability; NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, it is hereby agreed as follows: Section I. Enrolment and Determination of Eliaibilitv A. The Employer shall: (1) be responsible for interpreting the Plan and its provisions, its terms, conditions and operation; and (2) notify Plan Participants of their ability to apply for reimbursement benefits and supply them with Request forms (to be provided by AFLAC) and Request filing instructions; and (3) provide AFLAC with the names, addresses, Social Security Numbers, and elected amounts of all participants in the Plan; and (4) upon the occurrence of events that would change a Participant's status under the Plan (e.g. termination, Change in Status, Change in Cost or Coverage for DOC, etc.) immediately provide AFLAC with updates (via Telefax) which identify eligible Participants in each of the respective reimbursement Plans and/or the amount of reimbursement benefits for whidt they are eligible; and (5) immediately inform AFLAC (via Telefax) as to any new Participants in either of the reimbursement Plans, any Change in Status affecting a Participant's election, or any Qualified Beneficiary electing coverage under COBRA and the amount of such election (if COBRA applies to the Employer), or of any other change which will affect AFLAC's responsibilities hereunder. B. In determining any person's right to benefits under the Plan, AFLAC shall rely on the eligibility information furnished by the Employer, and any signed statements by Participants regarding the eligibility of their Requests under the respective Plan. It is mutually understood that the effective performance of this Agreement by AFLAC will require that it be advised on a timely basis by the Employer during the continuance of this Agreement of the identity of individuals eligible for benefits under each of the respective reimbursement Plans. Information modifying a Participant's.eligibility or status/election under either reimbursement Plan shall identify the effective date of eligibility and the termination date of eligibility and shall be provided to AFLAC (via Telefax) prior to the effective date of such modification in order to be considered by AFLAC in making benefit determinations hereunder. AFLAC shall not be responsible for Requests paid in error where the Employer has failed to iAform AFLAC (in a form and with such information as may reasonably be required by AFLAC) of a Participant's eligibility or status change prior to the release of the benefit payment. Section II. Fundina and Payment of Reauests for the Plan Benefits A. Select one below: o Daily Processing Option. The Employer shall: (i) make sufficient funds available from its general assets for amounts allocable to eligible reimbursement benefits under its plan by depositing a "Maintenance Deposit" (in amounts specified by AFLAC from time to time) in an Employer-owned and named account (the "Account") in a financial institution selected by the Employer and AFLAC to facilitate the timely processing of Requests under the Plan. 1 RSA I' [Note: the Account should not be opened in the Plan's name]; and (ii) grant AFLAC withdrawal authority over the Account sufficient to enable it to pay benefits under the Employer's FSA Plans; and (iii) deposit additional funds (at the request of AFLAC) in order to reestablish the Maintenance Deposit at the end of each Request processing cycle (or such earlier time specified by AFLAC); and (iv) telefax copies of all deposit verification receipts, Account Statements, and other correspondence relating to the Account to AFLAC upon receipt of such correspondence from the financial institution; and (v) during the term of this Agreement, the Employer shall not withdraw funds from the Account; except at the request of, or to the extent approved by AFLAC. The Employer bears sole responsibility for any fees irrposed with respect to the Account by the financial institution, including, but not limited to: Account maintenance fees, insufficient funds fees, fees with respect to voided checks, etc.; and (vi) authorize AFLAC to access the Account by: D D entering into a Withdrawal Agreement with CB&T; or if a Financial Institution other than CB& T is designated below, the Employer hereby authorizes AFLAC to: a) draw benefit checks directly on the Account; b) electronically transfer benefit payments from the Account; c) electronically access Account information: and d) execute the financial institution's standard Deposit/Account Agreement on the Employer's behalf (subject to the terms and conditions set forth herein and as AFLAC may otherwise establish). Name, address and contact person at other financial institution: D Standard Option. The Employer shall: (i) make sufficient funds available from its general assets for amounts allocable to eligible reimbursement benefits under its Plan; and (ii) draw an aITlOOnt equal to the aggregate amount of all Requests payable under the Employer's Plan and electronically transfer it to AFLAC (within three (3) business days of receipt of a request for such funds from AFLAC) for which there are eligible outstanding Requests (pursuant to the terms of the Plan). D Self-Pay Option. The Employer shall: (i) make sufficient funds available from its general assets for amounts allocable to eligible reimbursement benefits under its Plan; and (ii) review AFLAC's initial reimbursement determinations and issue reimbursement checks from its general assels within seven days of the receipt thereof for those Requests which are reimbursable pursuant to the terms of its Plan; and (iii) upon request, provide AFLAC with proof of timely benefit check disbursements in a form and manner deemed acceptable by AFLAC (e.g., bank issued account statements or check register). If, at any time, the amount of reimbursement benefits payable under the applicable Plan provisions exceeds the amount deposited by the Employer in the Account, the Employer shall transfer an amount necessary to the Account to fulfill its reimbursement obligations under the applicable Plan before any further reimbursement benefit payment is made. AFLAC is under no obligation to advance funds on behalf of the Employer. B. AFLAC, as agent for the Employer. shall provide those services described in Appendix A (attached hereto): 2 RSA " . - - - c. == --- - - LO - -.:t == I'-- C") --- == == D. == == - E. = == - - - - Lt) -.:t - 0 0 - 0 - N - ..... ..... = ~ N - 0 - ..... - Lt) . . . '. (1 ) Upon written request submitted to AFLAC's FLEX ONE@Department, AFLAC may provide limited assistance with certain of the nondiscrimination tests. The terms and conditions (including applicable fees) under which such services are provided are set forth in Appendix B "Nondiscrimination Testing and Form 5500 Preparation Services". (2) Upon written request submitted to AFLAC's FLEX ONE@ Department at the close of each Plan Year, AFLAC may assist with the preparation of Form 5500 for the Plan. Such request must be mad e within 120 days after the end of each Plan Year. The terms and conditions (including applicable fees) under which services are provided are set forth in Appendix B -Nondiscrimination Testing Services and Form 5500 Preparation Services". 11'1 providing services, AFLAC shall assume that ERISA and COBRA apply to the Employer's Plan unless the Employer gives AFLAC written direction otherwise. C. AFLAC shall not be obligated or responsible for any duty with regard to the administration of the Plan (imposed by the Plan or otherwise) except as specifically provided above. Employer has carefully reviewed and agrees to be responsible for the "Plan Sponsor Responsibilities" summarized on the back of the Plan Document Request (PDR) Form. Without limiting Employer's responsibilities described therein, it shall be the Employer's sole responsibility (as Plan Administrator) and duty to: ensure compliance with COBRA; perform required nondiscrimination testing; amend the Plan as necessary to ensure ongoing compliance with applicable law; file any required tax or governmental returns (including Form 5500 returns) relating to the Plan to determine if and when a valid election change has occurred; handle Participant claim appeals; allow AFLAC, by and through independent associates, a reasonable opportunity to discuss AFLAC, URM, and DOC benefits; execute and retain required Plan and claims documentation; and take all other steps necessary to maintain and operate the Plan in compliance with applicable provisions of the Plan, ERISA. the Code and other applicable Federal and State laws. Do In the event that AFLAC overpays any person entitled to benefits under the Plan, or pays benefits to any person who is not entitled to them, AFLAC shall take all reasonable steps to recover the overpayment except that AFLAC shall not be required to initiate court proceedings to recover an overpayment. AFLAC shall promptly notify the Employer if it is unsuccessful in recovering any overpayment. E. AFLAC will optically scan and maintain electronic copies of all FSA Reimbursement Requests and supporting documentation for a period of seven (7) years after the claim is processed. Copies of FSA claim documents can be reproduced upon written request at AFLAC's currently prevailing rate. Section III. Liabili~ and Indemni~ A In performing its obligations under this Agreement, AFLAC neither assumes nor underwrites any liability of the Employer under the Plan, but with respect to the Employer, acts only as provider of those services specifically described in Section II.B. of this Agreement and with respect to Plan Participants, acts only as the agent of the Employer. The services to be performed by AFLAC shall be ministerial in nature and shall be performed within the framework of policies, interpretations, rules, practices, and procedures made or established by the Employer. AFLAC shall have no discretionary authority or discretionary control over-any assets of the Employer, the Plan, or Plan Participants. B. AFLAC shall have no duty or obligation to defend any legal action or proceeding brought to recover a Request for Plan Benefits. AFLAC shall, however, make available to the Employer and its counsel, such evidence relevant to such action or proceeding as AFLAC may have as a result of its processing of the contested benefit determination. Except as otherwise explicitly provided in this Agreement, the Employer shall retain the liability for all Plan Benefit Requests and all expenses incident to the Plan and for any and all violations of the Consolidated Omnibus Budget Reconciliation Act of 1985 (UCOBRA"), if applicable, and agrees to indemnify AFLAC for and hold it, its directors, officers, and employees, harmless from all amounts and expenses (including reasonable attorneys' fees and court costs) for which AFLAC may become liable. This indemnity shall survive the termination of this Agreement. AFLAC shall use ordinary and reasonable care in the performance of its duties, but shall not be liable to the Employer for mistakes of judgment or other actions taken in good faith unless such error results directly from an intentionally wrongful or grossly negligent act of AFLAC, its officers or employees. AFLAC shall have no duty or obligation with respect to Requests incurred prior to the effective date of this Agreement (hereafter "Prior Reimbursement Requests") and/or Plan Administrator (or other) services arising prior to the effective date of this Agreement regardless of whether such services were/are to be performed prior to or after the effective date of this Agreement (hereafter "Prior Administration"). The Employer specifically acknowledge(s) and agree(s) that: (i) AFLAC has no responsibility or obligation with respect to Prior Reimbursement Requests and/or Prior Administration; (ii) the Employer will be responsible for processing 3 RSA .- Prior Reimbursement Requests (including any run-off Requests submitted after the effective date of this Agreement) and maintaining legally required records of all Prior Reimbursement Requests and Prior Administration sufficient to comply with applicable legal (e.g., IRS substantiation) requirements and (iii) the Employer agrees to indemnify and hold AFLAC harmless for any liability relating to Prior Reimbursement Requests and/or Prior Administration. .; F. The Employer agrees that AFLAC may communicate confidential, protected, privileged or otherwise sensitive information to Employer through the Named Contact (as designated on the Plan Document Request Form) and specifically agrees to indemnify AFLAC and hold it harmless: i) for any such communications directed to the Employer through the Named Contact attempted via telefax, mail, telephone, e-mail or any other media, acknowledging the possibility that such communications may be inadvertently misrouted or intercepted; and ii) from any claim for the improper use or disclosure of any health information by AFLAC where such information is used or disclosed in a manner consistent with its duties and responsibilities under this Agreement. Section IV. Reimbursement Reauest Processina Service Fee A. The Employer shall pay AFLAC a fee for services performed under this Agreement in the amount of $ 0.00 per Participant per FSA benefit (DOC or URM) per month (max per Participant of $ 0.00) with a minimum monthly fee of $0.00 for the reimbursement Plans (URM and/or DOC) for which services are rendered. This amount shall be due by the tenth (10th) of each month (or portion thereof) for which this Agreement is in effect and is in addition to and separate from: (i) any Account Establishment (or "Set Up") fee assessed by AFLAC of $ 0.00 to initiate the reimbursement arrangement; and (ii) the Employers obligation to make available sufficient funds to satisfy its obligations under the Plan and to make benefit disbursement in accordance with section II-^. above. The Employer is responsible for paying the Service Fee to AFLAC. AFLAC is not authorized to withdraw the Service Fee from the Account. Failure to pay any applicable monthly Service Fee by the next monthly Requests processing cycle shall result in a cessation of Request processing services until such fees are received by AFLAC. If Request processing services are pended for an entire monthly processing cycle, AFLAC may terminate this Agreement in accordance with Section VI. B. AFLAC may revise the Service Fee for services performed under this Agreement effective on each Anniversary Date of this Agreement by giving the Employer written notice of the revised rate at least thirty (30) days prior to the applicable Anniversary Date. C. Notwithstanding any other agreement between the parties (and/or their agents), AFLAC may revise the Service Fee set forth above at any time if revision is deemed necessary by AFLAC by reason of: i) modification or amendment of the Plan by the Employer; ii) a significant decrease in the number of AFLAC policies purchased by Participants under the Plan below the number initially included in the Plan after the Service Fee was established (or if later, when the Service Fee was last revised); or iii) a suspension, limitation, or revocation of the right of Employees or Participants to purchase AFLAC policies under the Plan. AFLAC shall advise the Employer of the revised Service Fee at least thirty (30) days prior to its implementation. If the Employer does not terminate this Agreement (by written notification pursuant to Section VI.A.1.) within thirty (30) days after the receipt of a notice of such revision, the Employer shall be deemed to have agreed to such revision for the remainder of the term of the Agreement. Thereafter, the Service Fee on and after the implementation date shall be made on the basis of such revised Service Fee. D. AFLAC may revise the Service Fee set forth above at any time if any change in law or regulations imposes on AFLAC greater duties or obligations than contemplated by the Agreement in force at the time of such change. Section V. Term of Aareement The initial term of this Agreement shall be the initial Plan Year commencing on the effective date hereof, thereafter, this Agreement will automatically renew for successive periods of twelve (12) months unless, at least thirty (30) days prior to the end of the then current term, the Employer or AFLAC gives written notice to the other of its intention not to renew the Agreement. In the event of a short plan year (other than the first plan year) this Agreement shall automatically renew for an additional twelve (12) months unless the Employer or AFLAC gives written notice to the other of its intention not to renew the Agreement within three (3) days after the Employer notifies AFLAC of the short plan year. Section VI. Termination of Aareement A. This Agreement shall terminate upon the earliest of the following dates: (1) The end of a term of the Agreement following the delivery of written notice of termination pursuant to Section V. (2) At the option of AFLAC, the date upon which the Employer fails to transfer sufficient funds to AFLAC (upon request by AFLAC): i) to pay all valid Requests pending under the Plan; or ii) to pay 4 RSA ., the Service Fee (as provided in Section IIAand IVA, above). AFLAC shall promptly communicate its election of this option to the Employer. (3) Upon the implementation date for a proposed Service Fee increase deemed to be unacceptable by the Employer (after delivery of written notice of termination by the Employer) pursuant to Section IV.C. (4) At the option of AFLAC, if no Plan Participant is an AFLAC policyholder or if the Employer denies AFLAC a reasonable opportunity (as determined by AFLAC in its sole discretion) to meet with Employees, AFLAC shall immediately communicate its election of this option to the Employer. (5) Any other date mutually agreeable to the Employer and AFLAC. B. Upon termination of this Agreement, AFLAC shall cease the processing of all Requests then in its possession, return any undistributed funds to the Employer, and make all records relating to Requests in process reasonably available to the Employer. If the termination occurs pursuant to VIA1. (above), AFLAC shall process all run-off claims provided any Service fee(s) is current. Thereafter, the Employer and/or Plan Administrator shall be responsible for all aspects of Reimbursement Requests processing and Plan administration. Section VII. Miscellaneous (1) Notices. Any notice required to be given hereunder to AFLAC shall be sufficient if in writing and delivered personally or by prepaid first class mail to AFLAC Administrative Services/Flex On~. 1932 Wynnton Road, Columbus, GA 31993-9615, or if to the Employer, at the address of the Employer denoted on the signature page attached hereto. (2) Applicable Law. This Agreement shall be governed by, and shall be construed in accordance with the laws of the State of Georgia, to the extent they are not preempted by ERISA, the Code, or any other Federal law. (3) Legal and Tax Status. The Employer acknowledges that neither AFLAC nor its agents is providing legal or tax advice, and that neither AFLAC nor its agents serves as the plan administrator or a plan administrator or a fiduciary under the Plan. The Employer shall be the sole party responsible for determining the legal and tax status of the Plan under applicable law. AFLAC shall have no power or authority to waive, alter, breach or modify any terms or conditions of the Plan. (4) Assignment. This Agreement may be assigned by AFLAC to any other party, including any successor to the business of AFLAC by merger, consolidation, purchase of assets, or otherwise, without the prior consent of the Employer. This Agreement shall be binding upon any corporation into which the Employer may be merged or with which it may be consolidated, or any corporation succeeding to all or substantially all of the business of the Employer. (5) Entire Contract. This Agreement constitutes the entire contract between the parties and no modification or amendment hereto shall be valid unless in writing and signed by an officer of the Employer and an Officer or duly authorized representative of AFLAC. (6) == -- - (7) -- -- - !!!!!! co - -.:t - I'-- - C") -- - - -- -- - == == - - - == -- == - L.O -.:t - 0 == 0 0 - N ..... ..... = ~ N - 0 == ..... 'f' Tax Reporting and Withholdings. The Employer has ultimate control over the payment of Plan benefits and shall be the sole party responsible for income and employment tax reporting and withholding obligations imposed as a result of the includability of such payments in the gross income of recipients. AFLAC is a mere agent of the Employer for the processing of benefit Requests. Confidential Information The term "Confidential Information" as used in this Agreement means confidential or proprietary information of any party that is not generally known to the public, including, but not limited to compilations, lists of actual or potential customers or suppliers, hardware systems, software, or other documentation of any type, whether in printed or machine readable form, computer databases, forms and form letters, contracts, information regarding specific transaction and marketing and business plans. For the purposes of this subsection, Confidential Information shall not include the personally identifiable information relating to any of Employer's employees. The term "Trade Secrets" as used in this Agreement shall mean Confidential Information that: (1) derives economic value, actual or potential, from not being generally known to, and not being readily ascertainable by proper means by, other persons who can obtain economic value from its disclosure or use; and (2) is the subject of efforts that are reasonable under the circumstances to maintain its secrecy. The terms "Confidential Information" and "Trade Secrets" do not include information that: (a) is known to the receiving party prior to its disclosure by the disclosing party, as evidenced by the receiving party's written records; (b) is developed by the receiving party independently of any of the Confidential Information or Trade Secrets received in confidence from disclosing party, evidenced by the receiving party's written records; 5 RSA (c) is rightfully received by the receiving party from a third party without restriction and without breach of . any obligation of confidentiality running to the disclosing party. Each party agrees that it shall not disclose to others or use for any purpose other than performance of the Agreement any of the other party's Confidential Information or Trade Secrets any time during or after the term of this Agreement. Each party further agrees that it will disclose Confidential Information or Trade Secrets to its employees only as necessary for the performance of the Agreement, and only to employees with a need to know. Each party to this Agreement agrees that all Confidential Information and Trade Secrets are the property of the party disclosing it, and each agrees to promptly return to the disclosing party, upon demand, any Confidential Information or Trade Secrets furnished under this Agreement which is either received in or reduced to material form, and all copies thereof. The Employer agrees that AFLAC may make lawful references to Employer in its marketing activities. . (8) Individual Information. Each party acknowledges that performance of the Agreement may involve the use and disclosure of personal information relating to the Employer's employees (including but not limited to names, addresses, benefit elections, claims and health information). AFLAC agrees that it will not use any such information disclosed to it by Employer except as authorized by the individual to whom the information relates or as otherwise permitted by applicable State or Federal law or regulation. Employer agrees that it will not use any such information disclosed to it by AFLAC except for the purpose for which it received the information and will not further disclose such information without the written authorization of the individual to whom the information relates. This provision is not intended to create any third party beneficiary rights (in favor of Employer's employees or any other party). (9) Capitalized Terms shall have the same meaning as in the Plan documents. IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed in duplicate and signed by an Officer of the Employer and an Officer or duly authorized Worldwide Headquarters Employee of AFLAC to do so. Dated at AFLAC this day of BY:~ iJrL. f)~ Robert M. Ottman Second Vice President AFLAC Administrative Services/Flex Onetlil this 1.:z.~L day of ~.uJ) ;l.-(JOtit, II, City Manager s. Osceola Avp, r.lp~ruT~rpr VL 33756 Attest: fkJ~t ~~~,~~ 0- Cynt . . Goudeau, City Manager Counters' ed: City Attorney 6 RSA I - - - - - - == I'-- - -.:t - I'-- - C") - == -- == == == - - - - - - - - - L() -.:t - 0 == 0 0 N - ..... ..... ~ ~ -- N -- 0 == ~ 'fl '~ Appendix A Schedule of Services to Be Provided By AFLAC In accordance with attached Reimbursement Services Agreement AFLAC shall provide the following services for the Employer: General Plan Services: provide the Employer with a sample cafeteria plan document, including a medical care expense reimbu rsement ("URM") Plan and a dependent care expense reimbursement ("DOC") Plan to be reviewed by the Employer and its legal counsel; and provide the Employer with a sample flexible benefits summary plan description for distribution to each Plan Participant and employees and where may be required by a Change in Status; and upon receiving instructions from the Employer on a Change in Status, AFLAC will make the change requested by the Employer. Additional Services if DOC or URM Benefits Are Offered: assist the Employer in explaining the URM and/or DOC featlJres of the cafeteria plan to employees; and process for the Employee-executed salary redirection agreements as they relate to the URM and DOC components of the Employer's flexible spending account; and prepare an enrollment confirmation letter and send it to the Employer to verify URM and DOC elections; and provide each Participant with a URM and/or DOC statement on a quarterly basis; and provide the Employer with written monthly reports summarizing the previous period's URM and/or DOC and Account activities; and receive Requests for URM and/or DOC benefits, and expeditiously review such Requests to determine what amount, if any, is due and payable with respect thereto; and disburse the benefit payments it determines to be due (provided the Employer transfers sufficient funds to AFLAC or has sufficient funds in the Account) or if Self-Pay is elected under Section II. A., notify the Employer of the benefit determination in accordance with the provisions of the Plan and the following procedures: valid reimbursement for URM and/or DOC benefits shall be paid by AFLAC on the date funds are received from the Employer (with respect to such Requests) by mailing a check in the appropriate amount(s) directly to the Participants at their home addresses; and if the amount of the (otherwise) reimbursable DOC Request exceeds the amount the Participant had withheld for DOC benefits, the excess shall be carried forward (within the same Plan Year) and treated as an Eligible Employment Related Expense for that month; and if the amount of the reimbursable URM Requests exceeds the amount the Participant has had withheld from URM benefits, the entire amount shall be processed (provided the Employer makes available sufficient funds for AFLAC to satisfy the Request); and Requests of less than $15.00 may be carried forward and aggregated with future Requests until the reimbursable amount is greater than $15.00, provided however, that the entire amount of the reimbursable Requests shall be paid after the close of the Plan Year without regard to the $15.00 threshold; and under the Daily Processing Option, checks of $2,000 or more shall be forwarded to the Employer for countersignature and diSbursement; and unless otherwise specified in writing by the Employer, Health FSA claims following a Change in Status impacting the Health FSA election shall be processed using a "blended approach" i.e., the maximum Health FSA benefit for a period of coverage following a Change in Status will be limited to the lesser of: a) the annual Health FSA maximum set forth in the Plan document less any benefit payments made prior to the Change in Status; and b) the sum of the Participant's Health FSA Account balance immediately before the Change in Status and any additional contributions made during the remaining period of coverage; and 7 RSA notify claimants as to any Requests which are denied because of inadequate Request substantiation or improper Request form submission and give affected claimants the opportunity to resubmit their Requests; and . provide to the claimant within ninety (90) days following receipt of a Request, written notification: (a) as to the disposition of the Request, or (b) of an anticipated delay beyond ninety (90) days in the disposition of the Request together with an explanation of the delay; and notify the claimant and refer to the Employer (with an analysis of the issues affecting the Request) for final decision, any Requests which AFLAC deems not to be reimbursable pursuant to the terms of the Plan and/or the reimbursement practices and procedures established by the Employer, setting forth the applicable review procedure available to the claimant through the Employer; and provide the Employer with written monthly and year-end reports summarizing the previous period's URM and/or DOC and Account activities with sufficient detail to provide for the audit and control of funds used; and provide the Employer with the information needed with respect to the URM and/or DOC Plans for fulfilling annual reporting requirements and the preparation and submission of a Form 5500 Series Annual Report by the Employer to the Internal Revenue Service. 8 RSA '. '.1), APPENDIX B Nondiscrimination Testing Services and Form 5500 Preparation Services [Provided Upon Annual Request] Nondiscrimination Testing: The Employer, upon submission of an annual Employee Census Data Sheet, authorizes AFLAC to compile nondiscrimination testing percentages based upon the employee census data provided. As consideration for this service, the Plan Sponsor/Administrator agrees to release and hold AFLAC, its subsidiaries, affiliates, officers, directors, owners, shareholders, attorneys, successors and assigns harmless from any liability arising as a result of the provision of, or reliance upon such testing percentages. In addition, the Employer understands and agrees that: AFLAC is not in the business of providing legal or tax advice. and the Employer, as the plan sponsor/administrator, will not construe the testing percentages provided by AFLAC to be legal or tax advice. Accordingly. the Employer will seek the advice of its own tax or legal advisor to interpret and verify the testing percentages provided, and ensure compliance with applicable nondiscrimination requirements. The Employer bears sole responsibility for nondiscrimination testing and the continued qualified status of its cafeteria plan under all applicable provisions of the Internal Revenue Code. The testing percentages provided by AFLAC are merely an indicator of compliance with two of the applicable nondiscrimination tests - the Cafeteria Plan 25% Key Employee Concentration Test and the Dependent Care 55% Average Benefits Test. Each Employer must also ensure compliance with the Eligibility Test and Contributions and Benefits Test applicable to the Cafeteria Plan, the URM, and the DOC Plan, as well as other tests that may apply to the benefits offered through the Cafeteria Plan. To ensure compliance with applicable provisions of the Internal Revenue Code, additional nondiscrimination testing and result verification must be undertaken by the Employer with the assistance of its tax or legal counsel. Discrimination testing should be conducted at least 180 days prior to the end of the Plan Year to which the data relates to ensure adequate time to make any required corrections. AFLAC will assist with discrimination testing no less frequently than once per year and no more frequently than once every thirty (30) days. Form 5500 Preparation: The Employer. upon submission of an annual Request for Form 5500 Filing Assistance. Plan Sponsor and Cafeteria Plan Information Data Sheet, authorizes AFLAC to prepare a sample Form 5500 and applicable schedules based upon the information it provides regarding the company and its cafeteria plan. In consideration for this service, the Employer agrees to release and hold AFLAC. its predecessors, representatives, agents, associates, employees, parent companies. subsidiaries, affiliates, officers, directors, owners, shareholders. attomeys, successors, and assigns, harmless from any liability arising as a result of the provision of, or reliance upon such sample forms. In addition, the Employer understands and agrees that: AFLAC is not in the business of providing legal or tax advice, and Employer will not construe the completed sample 5500 forms to be legal or tax advice. Accordingly, the Employer should seek the advice of its own tax or legal advisor to verify that the form was properly completed and all required information included. and ensure compliance with all applicable regulations and requirements. The Employer bears sole responsibility for submitting the Form 5500 and all applicable schedules and the continued qualified status of its cafeteria plan under all applicable provisions of the Internal Revenue Code. = The completed 5500 and attached schedules are provided by AFLAC, upon request, for active FLEX ONE@ accounts, merely as a service to help fulfill the filing requirements set forth by Section 60390 of the Intemal Revenue Code for cafeteria plans. To ensure compliance with the applicable provisions of the Internal Revenue Code and ERISA guidelines, additional information or filings may be required as it pertains to other welfare benefrt plans sponsored by the EmployerlPlan Sponsor. !!!!iiiii ;;;;;;;;;0 = = 00 -.:t -I'-- -"" - = ;;;;;;;;;0 Providing AFLAC with the information needed to cO"1llete the Form 5500 does not constitute an actual filing with the Internal Revenue Service. The timely submission of the appropriate forms remains the responsibility of the Employer. = = = - - - - - If AFLAC has been asked to prepare sample Form 5500s after the filing deadline has passed, the Employer agrees to release and hold AFLAC. its predecessors. representatives, agents, associates, employees, parent companies, subsidiaries, affiliates, officers, directors, owners, shareholders, attorneys, successors, and assigns, harmless from any liability arising as a result of the late filing of the forms. - - - - - = - = ;;;;;;;;;0 = Lt) "<t 0 0 0 N ..... ..... ~ N 0 9 RSA ..... 'f'