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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 3 ARTICLE X: DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT Not offered as a part of the Cafeteria Plan. 10.3(b) Claims Run-Out period: Thirty (30) days. Sixty (60) days. Ninety (90) days. Other: 10.9 Reimbursement Upon Termination of Participation: Expenses incurred while a Participant may be reimbursed if submitted within Claims Run-Out Period identified in Section 10.3(b). Expenses incurred while a Participant may be reimbursed if submitted within 30 days following termination of participation. Expenses incurred during the Plan Year (whether while a Participant or after participation ceases) may be reimbursed if submitted within Claims Run-Out Period identified in Section 10.3(b). Other: 10.12(a) Grace Period: Does not apply to DC Account. Applies to the DC Account. 10.12(a)(1) Grace Period expires: N/A Two and one-half months after end of Plan Year. Other: 10.13(b) Other dependent care limitations are as follows: N/A Other: ARTICLE XI: HEALTH FLEXIBLE SPENDING ACCOUNT Not offered as a part of the Cafeteria Plan. 11.3(b) Claims Run-Out period: Thirty (30) days. Sixty (60) days. Ninety (90) days. Other: 11.3(c) Dependent means: As provided in the Basic Plan Document. Other: 11.3(e) Medical Expense means: As provided in the Basic Plan Document. Other: 11.8 The maximum reimbursement a Participant may receive for a Plan Year is: An amount equal to the maximum salary reduction contribution allowed under Code § 125(i). Other: $2,850 is the maximum election a Participant may make for a Plan Year. $500 is the minimum election a Participant may make for a PLan Year. For a short Plan Year, the maximum reimbursement is: Not applicable. Pro-rated. Unchanged. For Participants joining the Plan mid-Plan Year, the maximum is: Pro-rated. Unchanged. 11.9 Reimbursement Upon Termination of Participation: Expenses incurred while a Participant may be reimbursed if submitted within the Claims Run-Out Period identified in Section 11.3(b). Expenses incurred while a Participant may be reimbursed within 30 days following termination of participation. Other: 11.12(a) Grace Period: Does not apply to ME Account. Applies to the ME Account. 11.12(a)(1) Grace Period expires: N/A Two and one-half months after end of Plan Year. Other: 60 days from the last day of the Plan Year. 11.12(b)(1) Account carryover: Does not apply to ME Account. Applies to the ME Account. Maximum Account Carryover is: $_ _______ 11.12(b)(5) Carryover available to: N/A As provided in the Basic Plan Document. Only Participants who elect a benefit for the following Plan Year. 11.12(b)(6) Forfeiture of carryover: As provided in the Basic Plan Document. Other:_ _______ 11.17(e) Other limitations are as follows: None. Other: