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CAFETERIA PLAN <br />ADOPTION AGREEMENT FOR City of Orono <br />© 2020 Hitesman & Wold, P.A. MEDSURETY, LLC <br />Cafeteria Plan Adoption Agreement 1-888-816-4234, www.medsurety.com <br />2 <br /> <br />ARTICLE IV: CONTRIBUTIONS <br />4.1 Salary reduction contributions shall occur: <br /> Every payroll period. <br /> Only two payroll periods per month. <br /> <br />4.3 Amount of the Employer Contribution for the Plan Year is as <br />follows: <br /> None. <br /> Flex Credit amounts for the specific Plan Year are <br />indicated on the City of Orono Intranet, linked in the <br />document named “Flexible Spending Plan Credits.” <br />Employees can apply any remaining Flex Credits, after <br />enrolling in Group Medical or waiving Group Medical, <br />towards Group Dental, FSA, LPFSA, DCAP and/or any <br />remainder can be taken as cash. <br /> <br />4.3 The Employer Contribution shall be provided as follows: <br /> No Employer Contribution. <br /> Per pay period. <br /> Per month <br /> Per quarter. <br /> Per year on or about the first day of the Plan Year. <br /> Other: <br />4.3 Restrictions on use of Employer Contribution: <br /> No Employer Contributions. <br /> Employer Contribution may be used as flex credits <br /> Employer Contribution is available only to provide cash in <br />lieu of Group Medical Benefits <br /> Other: May be used as Flex Credits to pay for Group <br />Medical, Group Dental, FSA, LPFSA, DCAP and/or taken as cash <br /> <br />4.3 Employer Contributions during leaves of absence (other than <br />FMLA): <br /> No Employer Contributions. <br /> Employer Contributions only during paid leaves. <br /> Employer Contributions during any leave. <br />4.3 Employer Contributions for mid-Plan Year enrollees: <br /> No Employer Contribution. <br /> Employer Contributions are prorated. <br /> Employer Contributions are not prorated. <br /> <br /> <br />ARTICLE V: ELECTIONS <br />5.1 Initial Elections: <br /> As provided in the Basic Plan Document. <br /> Other: <br /> <br />5.1(a) Use of Employer Contribution upon failure to make initial <br />Election: <br /> N/A – no Employer Contribution. <br /> Employer Contribution forfeited. <br /> Other: <br />5.3 Annual Elections: <br /> As provided in the Basic Plan Document. <br /> Other: <br />5.3(a) Use of Employer Contribution upon failure to make annual <br />Election: <br /> N/A – no Employer Contribution. <br /> Employer Contribution is forfeited. <br /> Other: Same as waiver of Medical, Flex credit - Can be <br />used for Group Dental, FSA, LPFSA, DCAP or taken as cash. <br />5.4 Irrevocable Election rules are: <br /> As provided in the Basic Plan Document. <br /> Modified as follows: <br /> <br /> <br />ARTICLE VI: ADMINISTRATION <br />6.1(b) Plan Administrator means: <br /> As provided in the Basic Plan Document. <br /> Other: <br />6.8(b) Electronic payment cards for Health Flexible Spending Accounts <br />are: <br /> N/A. <br /> Available. <br /> Not available. <br />6.8(c) Electronic payment cards for Dependent Care Flexible <br />Spending Account: <br /> N/A. <br /> Available. <br /> Not available. <br />6.8(d) Automatic reimbursements for Individual Premium Feature are: <br /> N/A. <br /> Available. <br /> Not available. <br /> <br />6.8(d) Automatic reimbursements for Individual Medical Premium <br />Feature are: <br /> N/A. <br /> Available. <br /> Not available. <br /> <br />ARTICLE VIII: GENERAL PROVISIONS <br />8.10 General law – State of Minnesota <br />