RES 1047RESOLUTION NO./0*/J
A RESOLUTION adopting and establishing the American
Family Life Assurance Company of Columbus (AFLACC)
Flexible Benefits Plan and authorizing the Mayor to sign the
Employers Acknowledgement for such plan..
WHEREAS,the City desires to offer its employees a flexible benefits plan whereby
employees can select insurance and fringe benefit programs suitable for their individual needs,
and
WHEREAS,the City desires to enter into an agreement with American Life Assurance
Company of Columbus (AFLACC)to provide such a flexible benefits plan,
NOW,THEREFORE,BE IT RESOLVED BY THE COUNCIL OF THE CITY OF CAMAS
AS FOLLOWS:
Section I
The City hereby adopts and establishes a flexible benefits plan with American Family
Life Assurance Company of Columbus (AFLACC),in accordance with the terms and conditions
of the Flexible Benefits Plan Summary Plan Description attached hereto as Exhibit "A"and by
this reference incorporated herein.
Section II
The Mayor is authorized to sign on behalf of the City the Employers Acknowledgement
form provided by AFLACC.
ADOPTED by the Council at a regular meeting this^0 ^day of March,2006.
Jl—SIGNED :
Mayor
ATTEST:
APPROVED a:
City Attorney
FLEXIBLE BENEFITS PLAN SUMMARY PLAN DESCRIPTION
PLAN INFORMATION SUMMARY
The Employer named below establishes a Flexible Benefits Plan (the "Plan")as set forth in this Summary Plan Description
("SPD")as of the Effective Date set forth below.The purpose of the Plan is to provide eligible Employees a choice between
cash and the specified welfare benefits described in this Plan Information Summary (see “Benefits Provided Under the Plan").
Pre-tax Contribution elections under the Plan are intended to qualify for the exclusion from income provided in Section 125 of the
Internal Revenue Code of 1986.
FLEXIBLE BENEFITS PLANEMPLOYERINFORMATION
1 )Name and Address of Employer:
Plan Administrator:
CITY OF CAMAS
JENNIFER GORSUCH
PO BOX 1055CAMAS,WA 98607
The Plan Administrator has the exclusive right to interpret the Plan and to decide all matters arising under the Plan,including the
right to make determinations of fact and to construe and interpret possible ambiguities ,inconsistencies ,or omissions in the Plan ,
and this SPD.
(206 )834-24622)Employer 's Telephone Number:
Employer's Federal Tax
Identification Number:
Plan Number Assigned to Cafeteria
Plan (e.g.,501 if this is the first ERISA
Plan Number assigned):
125 Start Date:
Effective Date of this Plan:
Last Day of the Plan Year:
Subsequent Plan Years:
Name and Address of
FSA Claim Administrator:
3 )
91-6001233
4 )
01/01/06
01/01/06
12/31/06
01/01-12/31
SAME
5 )
6 )
7 )
8)
JOAN M DURGINNameandAddressofregistered
agent for service of legal process :
9)
10)Affiliated Employers that will participate in the Plan (affiliates in excess of 30 are listed in Appendix 1):
OTHER11)Employer's Type of Business:
ELIGIBILITY
All Employees employed by the Employer shall be eligible to participate under the Plan except the following:
An eligible Employee may become a Participant in the Plan:
[]Immediately,upon the first day of employment (but not prior to the Effective Date of the Plan).
On the day following commencement of employment.
[]On the first day of the month following days of employment.
[X ]Other:1ST OF MTH FOLLOWING COMMENCEMENT OF EMPLOYMENT
provided the Employee completes a Salary Redirection Agreement (“SRA ”).However,eligibility for coverage under any
given Benefit Plan or Policy shall be determined by the terms of that Benefit Plan of Policy,and reductions of the
Employee's Compensation to pay Pre-tax or After-tax Contribution(s )shall commence when the Employee becomes
covered under the applicable Benefit Plan or Policy.
An eligible Employee may become a Participant in the Dependent Care and/or Medical Expense Reimbursement Plan(s )(if
elected below):
[]
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[]On the same day such Employee is eligible for the Pre-Tax Contribution benefits under the Plan.
[]On the day following commencement of employment.
[]On the first day of the month following days of employment.
=!£[]Other:OTHER,provided the Employee completes an SRA selecting such benefits .o
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Policy(ies )for each Participant and/or level of coverage is subject to the sole discretion of the Employer,and it may be
adjusted upward or downward in the Employer's sole discretion.The Nonelective Contribution amount will be calculated
for each Plan Year in a uniform and nondiscriminatory manner and may be based upon your Dependent status ,
commencement or termination date of your employment during the Plan Year,and such other factors that the Employer
deems relevant.In no event will any Nonelective Contribution be disbursed to you in the form of additional,taxable
Compensation except as otherwise provided in the enrollment material,
material ,the Employer may make available a certain amount of Nonelective Contributions and then allow you to
allocate the Nonelective Contributions among the various Benefit Plan(s )or Policy (ies )that you choose (subject to
restrictions described in the enrollment material).
Can I ever change my election during the Plan Year ?
Generally ,you cannot change your election to participate in the Plan or vary the Pre-tax Contribution amounts although
your election will terminate if you are no longer working for the Employer or no longer eligible under the terms of the
Plan.Otherwise,you may change your elections for Pre-Tax Contributions only during the Annual Enrollment Period ,
and then,only for the coming Plan Year.There are several important exceptions to this general rule:You may change
or revoke your previous election during the Plan Year if you file a written request for change with the Plan Administrator
(or its designated claims administrator )within 30 days of any of the following events :
To the extent set forth in the enrollment
Q-9 .
1.Change in Status .If one or more of the following "Changes in Status "occur,you may revoke your old election and
make a new election,provided that both the revocation and new election are on account of and correspond with the
Change in Status (as described below).Those occurrences that qualify as a Change in Status include the events
described below,as well as any other events that the Plan Administrator determines are permitted under
subsequent IRS regulations :
•a change in your legal marital status (such as marriage,legal separation,annulment,or divorce or death of
your Spouse );
•a change in the number of your tax Dependents (such as the birth of a child,adoption or placement for
adoption of a Dependent,or death of a Dependent);
•any of the following events that change the employment status of you,your Spouse ,or your Dependent that
affect benefit eligibility under a cafeteria plan (including this Plan and the Plan of another employer)or other
employee benefit plan of yours,your Spouse,or your Dependents.Such events include any of the following
changes in employment status:termination or commencement of employment,a strike or lockout ,a
commencement of or return from an unpaid leave of absence,a change in worksite,switching from salaried to
hourly-paid ,union to non-union,or part-time to full-time;incurring a reduction or increase in hours of
employment;or any other similar change which makes the individual become (or cease to be)eligible for a
particular employee benefit (NOTE:The specific rules governing election changes when you take a leave of
absence are described in Q-13 of this SPD);
•an event that causes your Dependent to satisfy or cease to satisfy an eligibility requirement for a particular
benefit (such as attaining a specified age,getting married,or ceasing to be a student);
•a change in your,your Spouse's or your Dependent's place of residence .
If a Change in Status occurs and you want to make a corresponding election change,you must inform the Plan
Administrator and complete a new election within 30 days from the date of the event.The election change must be
on account of and correspond with the Change in Status event as determined by the Plan Administrator with the
exception of special enrollment resulting from birth,placement for adoption or adoption,all election changes are
prospective.
As a general rule,a desired election change will be found to be consistent with a Change in Status event if the event
affects eligibility for coverage.A Change in Status affects eligibility for coverage if it results in an increase or
decrease in the number of Dependents who may benefit under the plan.In addition,you must also satisfy the
following specific requirements in order to alter your election based on that Change in Status:
•Loss of Dependent Eligibility.For accident and health benefits (e.g.,health,dental and vision coverage,and
Medical Care Reimbursement Plan),a special rule governs which types of election changes are consistent with
the Change in Status.For a Change in Status involving your divorce,annulment or legal separation from your
Spouse ,the death of your Spouse or your Dependent,or your Dependent ceasing to satisfy the eligibility
requirements for coverage ,your election to cancel accident or health benefits for any individual other than your
Spouse involved in the divorce,annulment,or legal separation,your deceased Spouse or Dependent,or your
Dependent that ceased to satisfy the eligibility requirements,would fail to correspond with that Change in
Status.Hence,you may only cancel accident or health coverage for the affected Spouse or Dependent.
Example:Employee Mike is married to Sharon,and they have one child .The employer offers a calendar year
cafeteria plan that allows employees to elect no health coverage,employee-only coverage,
employee-plus-one-Dependent coverage,or family coverage.Before the plan year ,Mike elects family
coverage for himself,his wife Sharon,and their child.Mike and Sharon subsequently divorce during the plan
year;Sharon loses eligibility for coverage under the plan,while the child is still eligible for coverage under the
plan.Mike now wishes to cancel his previous election and elect no health coverage.The divorce between Mike
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IN WITNESS WHEREOF ,the Employer has executed this Plan as of the date set forth below.
EMPLOYER'S ACKNOWLEDGMENT
As evidenced by the formal execution of this document,the undersigned Employer adopted and established this Plan on the
Effective Date as the Flexible Benefits Plan of the undersigned Employer.In doing so,the undersigned Employer acknowledges
that the Summary Plan Description (“SPD”)and this Plan document are important legal instruments with significant legal and tax
implications .
The Employer also acknowledges that it has read this SPD and the Plan document in their entirety ,has consulted independent
legal and tax counsel other than representatives of American Family Life Assurance Company of Columbus (Aflac ),to the extent
considered necessary ,and accepts full responsibility for participation of Employees hereunder and the operation of the Plan.
The Employer acknowledges that,as sponsor and Plan Administrator,it shall have sole responsibility to comply with all filing,
reporting,and disclosure requirements imposed by the DOL,IRS,or any other government agency,specifically including,but not
limited to,creating and filing Form 5500s and preparing and distributing SPDs and performing required nondiscrimination
testing.Furthermore,the Employer further acknowledges that it shall bear sole responsibility for amending the Plan as
necessary to ensure compliance with applicable tax,labor,and other laws and regulations .The Employer acknowledges receipt
of the checklist of Plan Sponsor Responsibilities included provided with the applicable plan document request form and has
agreed to the obligations set forth therein.
It is also understood and agreed that American Family Life Assurance Company of Columbus (Aflac),and its subsidiaries ,
agents ,and representatives,are not providing legal or tax advice to the undersigned Employer in connection with this Plan and
that no representations are made by it with respect to the operation of the Flexible Benefits Plan pursuant to the documents
provided by American Family Life Assurance Company of Columbus (Aflac)to the Employer.
This Plan shall be construed and enforced according to the Internal Revenue Code of 1986 ,as amended from time to time,the
applicable regulations thereto ,and the laws of the state of the principal place of business of the Employer .
IN WITNESS WHEREOF,the Employer has caused this Plan and Summary Plan Description to be executed on the day of
,to ratify the adoption of the Plan adopted and effective as of the Effective Date.
WITNESS:
Employer:
By:
Title:
Date:
Corporate Officer
ATTACHMENT I -SUMMARY PLAN DESCRIPTION
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