HomeMy WebLinkAboutContract 1847
VantageCare Retirement Health Savings Plan
Implementation Data Form - Page 1
Instructions to Employer: Provide necessary information to establish your plan properly.
Please contact your New Business Analyst at 1-800-326-7272, if you have any questions.
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ICMA RETIREMENT CORPORATION
ICMA-RC Use Only
1. Employer #
General
Information
City of Columbia Heights
2. (902) Employer's Full Name:
3. (924) Street Address:
(925)
590 40th Avenye N,E.
4. (918) City:
(919) State: MN
(92~)~;~m~Oid~: HessUil
5. (633) Primary Contact: Linda Magee
6. (634) Primary Contact Title: Assistant to the City Manager!Hqm.:ln Resources Director
7. (631) Primary Contact Telephone #: Ll~LJ 706~3609
8. (632) Fax#: (763) 706~3601
9. (PTOO) E-mail Address: Linda.Maqee(Olci.columbia-heiqhts.mn . us
10. (882) Employer's Federal Tax Identification Number:
41-6005069
11. # of Employees: 21 0
12. # of Employees Eligible for Plan Participation: 118
13. # of Employees Eligible to Receive Medical Benefits: 110
. Plan
Implementation
Information
14. Plan Level Quarterly Statements: (Note: * = default)
a. Sort Order: (629) 0 S=SSN* iii N=Name
b. Output Media: (627) Ga P=Paper* 0 M=Microfiche
c. Type: (626) Qg S=Summary* 0 D=Detail
15. (611) Contribution Information: (Note: * = default)
a. Frequency: (check one): .a (0) Bi-weekly*
o (1) Weekly
o (2) Semi-weekly
o (3) Bi-monthly
o ( ) Other:
o (4) Monthly
o (5) Semi-Monthly
o (6) Bi-quarterly
o (7) Quarterly
b. Deposit Medium:
(624) ~ Check *
o EFT
DWire
c. Data Medium: EZ Link Required to participate in RHS Plan
d. First Contribution Date Following Implementation: 7/8/05
o B=Bound
o (8) Semi-quarterly
o (9) Bi-annually
o (10) Annually
o (11) Semi-annually
:MA Retirement Corporation' Attn: Records Management Unit. P.O. Box 96220. Washington, DC 20090-6220' Toll Free 1-800669-7400
20
VantageCare Retirement Health Savings Plan
Implementation Data Form - Page 2
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Plan Contacts
(If any item #16-21 is left blank, the Primary Contact in #5 will receive mailings
ICMA RETIREMENT CORPORATION
Payroll Contact
Information 16. PTOl Contact Signature:
(200) Contact Name: Wendy Eckert
Please indicate (200) Contact Title: Prlyrnll/Ac:c:nllntin~ Cler
alternate
addresses in (420) Telephone: (lBJ 706-3629 Fax: (
Coments Section 17. PT08 Contact Signature:
(200) Contact Name:
(200) Contact Title:
(420) Telephone: (_) Fax: (
18. PT09 Contact Signature:
(200) Contact Name:
(200) Contact Title:
(420) Telephone: (_) Fax: (
Contribution 19. PT02 (200) Contact Name: Wendy Eckert
Contact (200) Contact Title: Payroll/Accounting
Information (420) Telephone: (L6..3.-) 706-3629
Trustee Contact 20. PT10 (200) Trustee Name: City of Columbia Hei
Information (200) Trustee Title: Finance Director
(200) Trustee Address: 590 40th Avp.n11 P. N,
Street
City Columbia Heights State M
(420) Telephone: (1.6..1.) 706-3626
Billing (Fees) 21. PT06 (200) Contact Name: N/A
Contact (200) Contact Title:
Information (420) Telephone: (_)
Comments:
(Alternate
Addresses for
#16-21 )
Internal Use
Onlv 641 912 608
- -
l<
1ll)
706-1617
-)
-)
Clerk
Fax: (763) 706-3637
ghts Attn: Will iam Elrite
F:
N Zip '1'1421
Fax: (163-) 706-3637
Fax: (_)
leMA Retirement Corporation. Attn: Records Management Unit. P.O. Box 96220 · Washington, DC 20090-6220 · Toll Free 1-800 669-7400
21
March 25, 2004
Linda Magee
City of Columbia Heights
590 40th Avenue NE
Columbia Heights, Minnesota 55421-3835
Re: VantageCare Retirement Health Savings Plan No. 800755
Dear Ms. Magee:
This letter agreement will serve to amend the existing Administrative Services Agreement
between City of Columbia Heights (the "Employer") and the ICMA Retirement Corporation
("ICMA-RC") to provide the City of Columbia Heights VantageCare Retirement Health Savings
(RHS) Plan for Employer's eligible employees ("Accountholders").
The existing Agreement between Employer and ICMA-RC is hereby amended as follows:.
1. Employer desires to make the RHS plan administered by ICMA-RC available to its
employees. The details of the RHS plan shall be as mutually agreed between Employer and
ICMA-RC, but in general shall be as set forth in the RHS plan materials developed by ICMA-
RC and provided to Employer. RHS plan materials shall include the Vantage Care RHS
Employer Manual, available electronically through the EZ Link System upon plan adoption.
2. Employer agrees that this Addendum and the terms set forth and referenced herein shall be
in effect for an initial term beginning on the date the Addendum is executed by the Employer
below and ending 5 years after that date. The Addendum will be renewed automatically for
each succeeding year unless written notice of termination is provided by either party no less
than 60 days before the end of such extension year.
3. Absent an explicit agreement to the contrary between ICMA-RC and Employer,
Accountholder fees and expenses shall be payable from RHS assets, in accordance with the
requirements of the RHS plan as set forth in paragraph 9 below.
4. Each Accountholder will receive a consolidated quarterly statement providing information for
any deferred compensation plan, qualified plan or RHS account maintained by each
Accountholder and administered by ICMA-RC.
5. Tax withholding and reporting will be provided by ICMA-RC and its agents in conjunction with
the Employer for each RHS Account administered by ICMA-RC.
6. Information required to be retained by the employer shall be set forth in the RHS plan
materials developed by ICMA-RC and provided to Employer.
7. The details of ICMA-RC's administration of the RHS plan, as well as other features of the
RHS plan, shall be as set forth in RHS plan materials. The RHS plan materials are hereby
incorporated by reference and made a part of this Agreement, except that Employer and
ICMA-RC may from time to time mutually agree in writing to terms that vary from the RHS
plan materials.
8. The Employer understands that, as ageneral matter, the Internal Revenue Service ("IRS")
may decline to rule on certain design features or provisions that the Employer may request to
have added to the RHS plan materials. The Employer agrees to hold ICMA-RC harmless in
connection with the addition and administration of any RHS plan feature or provision
requested by the Employer for which the IRS will not provide express interpretive guidance.
9. Accountholder's account administration fees will be paid from RHS assets according to the
following schedule:
a. Employer with ICMA-RC 9401 and 9457 retirement plan average participant account
balances of $25,000 or more:
A $30 annual account fee will be charged to each Accountholder's account. The fee will
be charged against the account on a quarterly basis. In addition, an annual asset fee of
0.30% (30 basis points) will be charged on a quarterly basis, based on the balance in the
account on the last day of the previous quarter.
b. Employer with ICMA-RC 9401 and 9457 retirement plan average participant account
balances of less than $25,000, or Employer who does not currently have a retirement
plan with ICMA-RC:
A $30 annual account fee will be charged to each Accountholder's account. The fee will
be charged against the account on a quarterly basis. In addition, an annual asset fee of
0.40% (40 basis points) will be charged on a quarterly basis, based on the balance in the
account on the last day of the previous quarter.
When the average participant account balance of the Employer's 3401 and 9457
retirement plans with ICMA-RC totals $25,000 or more (based on the balances in the
Employer's retirement plans on the last day of the previous quarter), the pricing detailed
in paragraph 9.a. shall apply beginning in the subsequent quarter.
For De Minimis account payments (as defined in the RHS plan materials), there will be a fee
of $25 collected at the time of disbursement.
Account administration fees are subject to change with appropriate prior notification.
If City of Columbia Heights finds these terms agreeable, please so indicate by having the
appropriate person sign and date this letter agreement in the space indicated below.
Very truly yours,
ILl 1 J<~
Paul Gallagher
Corporate Secretary
~;;:f.,/-
Authorized Official
c;;tf~~
/ ,/ Date
Agreed:
2
RESOLUTION 2005-29
ADOPTING THE V ANTAGECARE RETIREMENT HEAL TH SAVINGS (RHS) PROGRAM
WHEREAS, the City of Columbia Heights has employees rendering valuable services; and
WHEREAS, the establishment of a retiree health savings plan for such employees serves the
interests of the Employer by enabling it to provide reasonable security regarding such employees' health
needs during retirement, by providing increased flexibility in its personnel management system, and by
assisting in the attraction and retention of competent personnel; and
WHEREAS, the City of Columbia Heights has determined that the establishment of the retiree
health savings plan (the "Plan") serves the above objectives;
NOW, THEREFORE, BE IT RESOLVED that the City of Columbia Heights hereby adopts the
Plan in the form of the ICMA Retirement Corporation's VantageCare Retirement Health Savings
Program.
BE IT FURTHER RESOLVED, that the assets of the Plan shall be held in trust, with the City of
Columbia Heights serving as trustee, for the exclusive benefit of Plan participants and their beneficiaries,
and the assets of the Plan shall not be diverted to any other purpose prior to the satisfaction of all
liabilities of the Plan. The City of Columbia Heights has executed the Declaration of Trust of the City of
Columbia Heights Integral Part Trust in the form of the model trust made available by the ICMA
Retirement Corporation.
BE IT FURTHER RESOLVED, that the Assistant to the City Manager/Human Resources Director
shall be the coordinator and contact for the Plan and shall receive necessary reports, notices, etc.
I, William Elrite, Clerk of the City of Columbia Heights, do hereby certify that the foregoing resolution
proposed by Council Member Williams and seconded by Council Member Kelzenberg was duly passed
and adopted by the City Council of the City of Columbia Heights at a regular meeting thereof assembled
this 13th day of June 2005, by the following vote:
AYES:
NAYS:
Peterson, Williams, Ericson Diehm, Kelzenberg
Nawrocki
LJJL-f~
Willi8111 Elrite
City Clerk
E:MPLOYER V ANTAGECARE RETIREMENT HEALTH
SAVINGS (RHS) PLAN ADOPTION AGREEMENT
Plan Number: 800755
Employer Retirement Health Savings Plan Name:
City of Columbia Heights
Retirement Health Savings Plan
I. Employer Name: City of Columbia Heights
II. The Employer hereby attests that it is a unit of a state or local government or an agency or instrumentality of
one or more units of a state or local government.
III. The Effective Date of the Plan: July 1,2005
IV. The Employer intends to utilize the Trust to fund only welfare benefits pursuant to the following welfare
benefit planes) established by the Employer: City Policies and Union Contracts.
V. Eligible Groups and Participant Eligibility Requirements
The following group or groups of Employees are eligible to participate in the Vantage Care Retirement Health
Savings Plan:
All Employees
All Full-Time Employees
Non-Union Employees
Public Safety Employees-Police
Public Safety Employees-Firefighters
General Employees
Collectively-Bargained Employees (Specify unit)
x Other (specify below)
Those employees eligible under City policies and those union units that enter into a
Memorandum of Understanding with the City of Columbia Heights for participation in
the VantageCare Retirement Health Savings Plan.
The group specified must correspond to a group of the same designation that is defined in the statutes, ordinances, rules,
regulations, personnel manuals, or other material in effect in the state or locality of the Employer.
IJI Ifthis.boxiscb~ckeci, in'Ji6Jlofm~ndatory participation;tbeE:lIlplpyyt providlesf()ria.phe-t1lIl'e.ifr~voc;@.ie .........
electioDQyeligible'ElllpiqYyeS topartjc;ipatein RHS. ..lJntilsuch tin1(~;astheelectionis)n~d~; the Employee shalf'
not participate in the PI~nbrrec~iVe.cohtri1:)l~tionSPUrsl.laIltto SectionVI. . '.' .'.
!. .
. i, ..
. -.' .
NewlyeligibleEl11ploye~sshal1beprovidedan eleptioIl windpw qf60days (n9mote.tljfll19()~al~~Par'd~ysrft~)In
tlfedate.pfinitial elil5ibilityduriIlg wllichtheYIl1ay lll~ke. theele(;ti9~ t~,partjcipate;Particip~tipP.p:IaY1?yg;i11lJ,Q'
e~lierjl1aP,thecaleIidariI1onth fpl10wingtlie endoftheelec;t1oJ1Win'ciow. " ,'" '.' . .'...
, . .... .. - ._ ,_,. "',.,.....' ". '0' .. _!.. "'," .':'-;:
; ',' . -. ...e...._". -,.._, , .C,', ...., ,>
"<. ",' ',' " -"'" .," .,'.;""",.
. ",. co ".. _ '-"'..'" ",,,.,' ','.
. " ";'-'" '." ..;,' '''' ," ..,..,'....." .. ...... ....... "; .":.. ',:' <
If the :Ewplqyee dO(ls notlllalCetheelectionintpe ,year' ofmitiaJeli~i1~.ility, the~ie8tio#top~Iiipip'~t~w~).'p(l'mag~'
iJ1alat(lr.ye~. ..An apnu~lelflqtionFindow of60 ?ays (no 1110re th~6.0c~.lenqarclays}s4~UbeproYi~edql!fmw] .'
wl1ich~h(lelyctiol1maybelllade. The ele9tipl1'viJ1dowBl1~11 tll11from; Op!qberl t()N.Qverril:ler.2~, J,>arti~jp.!itjQri
lllfly\begul np parliertllanthec!il(;lnciar year foUowmg theY(l~oftheelecti()n.. ... .
. " .,
Oncemade,theeIectiolllsitrevQcable and may nqt berevokeq whUe theparticipantisamember ofthegrOlip
coven~dbytheRIISpl~n. .
If the Employer's underlying welfare benefit plan or funding under this VantageCare Retirement Health Savings Plan is in
whole or part a non-collectively bargained, self-insured plan, the nondiscrimination requirements of Intemal Revenue
Code (IRC) Section 105(h) will apply. These rules may impose taxation on the benefits received by highly compensated
Employees if the Plan discriminates in favor of highly compensated Employees in terms of eligibility or benefits. The
Employer should discuss these rules with appropriate counsel.
B. Participant Eligibility
1. Minimum period of service required for participation is one year.
2. Minimum age required for eligibility to participate is NI A.
VI. Contribution Sources and Amounts
A.
Mandatory Contributions
o 1. Direct Employer Contributions
The Employer shall contribute on behalf of each Participant _ % of earnings or $_
for the Plan Year.
Definition of earnings: Base wages
o 2. Mandatory Leave Contributions
The Employer will make mandatory contributions ofleave as follows:
Accrued Sick Leave *
DYes
o No
Accrued Vacation *
DYes
o No
Other * (describe) 0 Yes 0 No
*Please provide the formula for determining the Accrued Leave contribution:
An Employee shall not have the right to discontinue or vary the rate of annual leave
contributions.
o 3. Mandatory Employee Compensation Contributions
The Employer win malce mandatory contributions of Employee compensation as follows:
o Reduction in Salary - _% of earnings (as defmed in VI.A.l.) or $
will be contributed for the Plan Year.
o Decreased Merit or Pay Plan Adjustment - All or a portion of the Employees'
annual merit or pay plan adjustment will be contributed as follows:
An Employee shall not have the right to discontinue or vary the rate of mandatory
contributions of Employee compensation.
I
B.
.1
Elective Con trib utions
1. ElectivePre~TmcContributions .' . ". .... .' '. .... .... ..... ..... .
The Empl()yerwillpennit each E111ployee to make the following elections toinalce pre-taxconti.-iblitions
to the Plan:
'''1.. I~~ev?~~"I~ Ji]!.~IiQJl!r@Pr~,T axC911jri~UIiQits("."'().D1~~s~Ii.)l'; . ^QPi;'tiu;~,
irrevocable .electionofthe .lll11ountof Employer contributions ofqoll}petlsation made ()n,b1S or
her behalf.
The Employer limits thealllountelectedtoeither a fix'edpercentageora rangeof.percentages' 6fan
Employee's earnings.
:.::,% of earnings (as defined in VLA.1.) or up to 100% of earnings (as defined in VLAJ}forthe
Plan Year.
Newly eligible Employees shall be provided an election windowof60 days {no more tJ1an60) fromthe
date of initial eligibility during wl1ichthey may make the election to contribute. 'Contributions 111~yliegih
no earlier than the calendar month following the end of the electionwil1(low.
If the Employee does uotma}(e tl1eelection i~ theyearofiilitialeligibility,the electiontp contribute may
,be made in~ lateryear.Anamu~alelectionwindowo:f60cIays {no morethau pO) shan be provided '.
d~ring;whichtl1e electionmaybemade. The, electionwindowsqaHrun fr()m09top~r 1;10 Nove111ber29:, ,
Corttriputionsm~y begillno earlier than the. cale1l4arye~fol1owinlS the rear ()fth~election"
Ill'
0nce.mage,the'eJection isirrevoca.blea114 Illa.y not be r(;)voke&
b..' Irrev()c~bleElectioll'for.iPte..TaxQontrj~~tiC)ij~'()lA~c;rpedli~~Y~:,A;;()rie..iiwe,
. irrevocable election of:. the aIIl.ountofeI:l1ployercontributi()lls of El11ploy-eea9Cl}led:., . .
.rzlSiCl(
Ii] Yes D No
The Employer limits the amount elected as shown below:
Cash va1tle ofaccumul~ted unused sick ieave;cash.vaiue OfacctlI1111iat~d1.,ll1tlsed yacati(irl': '
. : .
1:J'I'vacation
D
Other
(deScrib~)lea'Vel11aaeon his/her behalf
Newly eligible. Employees shall be provided an election window of60. days (no m{)re than60cal~11c:lar
days) frOlJ1 the date of initial eligibility during whjchth(jywaymake theelectiont()contrlbllt(j,
Contributions 11ulyb~ginl1oearli(jr thaIl the,calerida,nllol1th f611ow~g the'endof theeleptionwill.qow.
If the Employee does 110tm~lcetheelectioni11the year ofi1J.itialeligibility, tlw election t9C()l1tril:!l1t~m~y
be made in a.lateryear .An 'annual election window of60 c:lay~<nomote tha1160'c~lel1darcl~ys)~h,~llbe .'
provicledduring;whichtheelectionmay be made. The electiol1windowshaI1rullfrpm()ctoberJtq
N overilber 29. COQtributions may begin .no earJjerthantlw calendw,yearfolJowingtheyei:ITp:ftpe
electi6il. .
Once1TIage,. tMelection isirrevQcableand may npt be J(;)voke4.
D
. .-
" "" ,. . ,. .
c.... Anllual'Prospective Elecfion for Pre-TaxContrilnItionsof L~a"e: " Ah'arini.ta.l,irrevocableelectionto
hayt;lhis orher '[]sicilc DvaQ~tion 0 otlwr .. (descdbe)1eavetobeaQcl1ledinthe l1~xt
calel1dar year contributed to the Plan on his or her behalf.
The Employer limits the amount elected as shown below:
Contributions of future leave accruals will be remitted to the Plan
o As earned
o Atthe end of the calendar year.
The election to contribute must be made in the calendar year before the year in which contributions are to begin. .
Once made, the election shall apply to succeeding calendar years unless otherwise revised or revoked by the
Employee orianannmil basis.
An al111ual election window of _days (no lllore than 60 calendar days) is provided dur1n&.which eli~ible
Employees may make the election to contribute. The electic>11winclow shall run from --'--'- to --'--'- (insert your
a1111ualtime frame for the election window). . . .. .. .
In adopting section. a, b,and/or c, theEmployeracknowledgestbat~helnternalRevel1ue Servicehasrtotruled on
irrevocable election contriblltions in. an.integralparttrust. lCMA -RC has obtained the advice of counsel that such
contributions are allowable under the conditions outlined illtms Acloptitm A.greement... The Employer should
discuss this issue with appropriate counseL
2. Voluntary After-Tax Contributions
Each Employee may contribute up to 25% of earnings (as defined in VLA.l.) or$ . . forthePlanYear on a
voluntary after-tax basis. In no event may aggregate Employee voluntary after-tax contributions exceed 25%of
total contributions in any Plan Year.
An Employee sh~tllhave the right to discontillueor vary the rate of elective after-tax contributionso:fEmployee
earniIlgs.
By adoptulg this sect~on,tl1(;l Employer acknowledges thattheInterncilRevenueService ha~ dedineCltbJlll~On
Employee. after taxcontribution$inan iIltegralpart trust. leMA -RChas.obtaint'ldthea4vice.ofcol.1nselthlltsuc~
contributions are allowable in an insubstantial aj1lOunt (i.e. no more than 25%oft.otalcontriblltions'in allY Plan .
Vflar). The. Employer should discuss this issqe with llppr.opriat.ecollnseL .
c. Limits on Total Contributions
The total contribution on behalf of each Participant (including both Mandatory and Elective Contributions) for each Plan
Year shall not exceed the following limit(s):
D
D
III
_% of earnings (as defined in VLA.l.)
$
There is no Plan-defined limit on the percentage or dollar amount of earnings that may be
contributed.
Limits on individual contribution types are defined within the appropriate section above.
See Section V.A. for a discussion of nondiscrimination rules that may apply to non-collectively bargained self-insured
Plans.
VII. Vesting Schedule
A.
The account is 100% vested at all times, unless specified otherwise in B, below.
B.
The following vesting schedule applies to Direct Employer Contributions outlined in VLA.l:
Years of
Service
Completed
Specified
Percent
Vesting
%
%
%
%
%
%
%
%
C.
The account will become 100% vested upon the death, disability, retirement, or attainment of
benefit eligibility by a Participant.
Definition of retirement:
D.
Any period of service by a Participant prior to a rehire of the Participant by the Employer shall
not count toward the vesting schedule outlined in B. above.
VIII. Forfeiture Provisions
Upon separation from the service of the Employer or upon reversion to the Trust of a Participant's account
assets remaining upon the participant's death (as outlined in Section XI), a Participant's non-vested funds shall:
D
D
D
1lI
Remain in the Trust to be reallocated among all Plan Participants as Direct Employer Contributions for
the next and succeeding contribution cyc1e(s).
Remain in the Trust to be reallocated on an equal dollar basis among all Plan Participants.
Remain in the Trust to be reallocated among aU Plan Participants based upon Participant account
balances.
Revert to the Employer.
In the case of separation from service, the Participant's non-vested funds shall be applied as shown above. In the case of
reversion due to the Participant's death under Section XI, the remaining account assets shall be applied as shown above.
IX. Eligibility Requirements to Receive Medical Benefit Payments from the VantageCare
Retirement Health Savings Plan
A. A Participant is eligible to receive benefits:
_ At retirement only (as defined in Section VILC.)
-X- At separation from service with the following restrictions: NO RESTRICTIONS
At age _ only
At retirement and age _
At retirement or age _
B. Termination prior to general benefit eligibility: A Participant who separates from the service of the
Employer prior to attaining benefit eligibility as outlined in Section IX.A. or C. will be eligible to receive
benefits:
III
D
Immediately upon separation from service.
At age _'
C. A Participant who dies or becomes totally and permanently disabled (as defined by the Social Security
Administration) will become immediately eligible to receive medical benefit payments from his/her
VantageCare Retirement Health Savings Plan account.
X. Permissible Medical Benefit Payments
Benefits eligible for payment consist of:
A. -X. All Medical Expenses eligible under IRC Section 213 * other than direct long-term care
expenses, OR
B. The following Medical Expenses (select only the expenses you wish to cover under the
Vantage Care Retirement Health Savings Plan):
Medical Insurance Premiums
Medical Out-of-Pocket Expenses*
Medicare Part B Insurance Premiums
Medicare Supplement Insurance Premiums
COBRA Premiums
Dental Insurance Premiums
Dental Out-of-Pocket Expenses*
Long Term Care Insurance Premiums
Other (Must be eligible under IRe Section 213)*
*See Section V'A. for a discussion of nondiscrimination rules which may apply to non-collectively bargained, self-insured
Plans.
XI. Death Benefit
In the event of a Participant's death, the following shall apply:
Account Transfer: The surviving spouse and/or surviving eligible dependents (as defmed in Section XIII.F.) ofthe
deceased Participant are immediately eligible to maintain the account and utilize it to fund eligible medical benefits
specified in Section X above.
Upon notification ofa Participant's death, the Participant's account balance will be transferred into the Vantagepoint
Money Market Fund*. The account balance may be reallocated by the surviving spouse or dependents.
*Please read the current prospectus carefully prior to investing. An investment in this fund is neither insured nor
guaranteed and there can be no assurance that the Fund will be able to maintain a stable net asset value of $1. 00 per
share. Vantagepoint Mutual Funds are distributed by ICMA-RC Services, LLC, a controlled affiliate of lCMA Retirement
Corporation. Member NASD/SIPC.
If a Participant's account balance has not been fully utilized upon the death of the eligible spouse, the account balance
may continue to be utilized to pay benefits of eligible dependents. Upon the death of all eligible dependents, the balance
will be available for medical benefits for the designated beneficiary of the last dependent or spouse to die. Assets
remaining upon the death of a designated beneficiary shall be available for medical benefits of the beneficiary's
designated beneficiary. If there is no living beneficiary(ies), the account will revert to the Plan to be applied as specified
in Section VIII.
There will be no elective withholding offederal, state, or local taxes for medical benefit payments to the Participant's
spouse's or dependent's designated beneficiarj(ies).
Ifthere are no living spouse or dependents at the time of death ofthe Participant, the account will be available for medical
benefits for the designated beneficiary(ies) of the Participant. Assets remaining upon the death of all designated
beneficiaries shall be available for medical benefits of the beneficiary's beneficiary. If there is no living beneficiary(ies),
the account will revert to the Plan to be applied as specified in Section VIII.
There will be no elective withholding of federal, state, or local taxes for medical benefit payments to the Participant's
beneficiary(ies) or any beneficiary's beneficiary.
XII. De Minimis Accounts
Upon separation from the service of the Employer prior to a Participant becoming eligible for medical benefits from a
VantageCare Retirement Health Savings Plan account, Participant accounts that are considered de minimis as specified
below will be paid to the Participant.
D
D
[7l
r.xJ
The de minimis account value shall be $5,000 or less.
The de minimis account value shall be $
(insert dollar amount between $0 and $5,000) or less.
The Plan shall not allow de minimis account distributions.
XIII. The Plan will operate according to the following provisions:
A.
Employer Responsibilities
1. The Employer will submit all VantageCare Retirement Health Savings Plan contribution
data via electronic submission.
2. Participant status updates and/or changes or personal information updates and/or changes
(Participants' termination dates, Participants' benefit eligibility dates, etc.) will be
provided via electronic submission.
B.
Participant account administration fees will be paid through the redemption of Participant
account shares, unless agreed upon otherwise in the Administrative Services Agreement.
C.
Employer plan fees will be paid by the Employer as outlined in the Administrative Services
Agreement.
D.
Assignment of benefits is not permitted.
E.
Payments to an alternate payee (payee other than a Participant) are not permitted with the
exception of reimbursement of health insurance premiums to the Employer.
F.
An eligible dependent is the Participant's lawful spouse and any other individual who is a
person described in IRC Section 152(a).
G.
The Employer will be responsible for withholding, reporting, and remitting any applicable
taxes, as outlined in the VantageCare Retirement Health Savings Plan Employer Manual.
XIV. The Employer hereby acknowledges it understands that failure to properly fill out this Employer
VantageCare Retirement Health Savings Plan Adoption Agreement may result in the loss of tax
exemption of the Trust and/or loss of tax-deferred status for Employer contributions.
EMPLOYER
By:
Title:
Attest:
Accepted: Vantagepoint Transfer Agents, LLC
Corporate Treasurer