10-10-2022 Council Packet - Laserfiche WebLink

Home Browse Search

CAFETERIA PLAN ADOPTION AGREEMENT FOR City of Orono © 2020 Hitesman & Wold, P.A. MEDSURETY, LLC Cafeteria Plan Adoption Agreement 1-888-816-4234, www.medsurety.com 1 This is the Adoption Agreement referred to in the Cafeteria Plan Basic Plan Document. The Adoption Agreement plus the Cafeteria Plan Basic Plan Document constitute the “Plan.” The Adopting Employer hereby makes the following representations and selections: EMPLOYER INFORMATION: EMPLOYEES: Employer Name: City of Orono Address: 2750 Kelley Parkway City, State Zip: Orono, MN 55356 Phone/Fax Number: 952-249-4600 / 952-249-4611 Type of Business Entity: Municipal Government / City Agent for Service of Legal Process: None Provided State of Incorporation: Minnesota EIN: 41-6008585 If the Plan Administrator is different than the Employer, please provide the following: Name: Employer / Ronald Olson Address: Same as above City, State Zip: Same as above, Phone/Fax Number: Same as above / rolson@ci.orono.mn.us There were more than fifty (50) Employees in the last twelve months? Yes No There were more than twenty (20) Employees in the last calendar year? Yes No PLAN INFORMATION: Check the one that applies (check only one box): Except as otherwise provided in the Basic Plan Document, the Optional Benefits are intended to comply with ERISA. The Optional Benefits are not intended to comply with ERISA, and any references to ERISA do not bind the Plan to comply with ERISA. Addendum(s) Attached? Yes No ARTICLE II: DEFINITIONS 2.10 Effective Date means: September 1, 2022 Is this a restatement: Yes No If Yes, original Effective Date: N/A Notwithstanding the foregoing, the amendment to Section(s) N/A of the Plan is effective on :N/A 2.16 Subsidiaries and/or affiliates participating in the Plan are:N/A 2.18 Entry Date means: September 1, 2022 2.27 Optional Benefit(s) means (check all that apply): 2.29 Plan Name means: City of Orono Cafeteria Plan 2.31 Plan Year commences on the first day of January and ends on the last day of December. A short plan year begins on September 1, 2022 and ends on December 31, 2022. Group Premiums: Group Medical Benefits Group Dental Benefits Group Term Life Benefit and/or Group AD&D Benefits Group Vision Benefits Group Disability Benefits Group Voluntary Insurance Benefits Other: Dependent Care Flexible Spending Account Health Flexible Spending Account Individual Premium Feature Individual Medical Premium Feature Limited Scope Health Flexible Spending Account HSA Contribution Feature Cash Payment ARTICLE III: ELIGIBILITY AND PARTICIPATION 3.1 Eligibility requirements are as follows (check and complete only those that apply): Eligible for coverage under the Employer’s Group Medical Plan Length of service: First of the month following thirty (30) days from the date of hire. Minimum number of hours: Average of thirty (30) hours of service per week. Employment Classification: All Other: 3.3(b) Special rule for new hires: As provided in the Basic Plan Document. Does not apply.