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© 2019 Hitesman & Wold, P.A. MEDSURETY, LLC Cafeteria Plan 1-888-816-4234, www.medsurety.com Basic Plan Document 11 5.4 Elections Irrevocable. For purposes of this Section 5.4, the term “dependent” shall m ean (a) a Tax Dependent if the election relates to health benefits, or (b) a Qualifying Individual (as defined in Article X) if the election relates to the Dependent Care Flexible Spending Account. Unless modified in the Adoption Agreement, an Election becomes effective and shall be irrevocable for the Plan Year or the remainder of the Plan Year except under the following circumstances: (a) Change in Status. A Participant may change or terminate his or her actual or deemed Election under the Plan upon the occurrence of a Change in Status, but only if such change or termination is made on account of and corresponds with a Change in Status that affects coverage eligibility of a Participant, a Participant’s Spouse, or a Participant’s Dependent (referred to as the general consistency requirement). The Plan Administrator (in its sole discretion) shall determine, based on prevailing IRS guidance, whether a requested change is on account of and corresponds with a Change in Status. Assuming that the general consistency requirement is satisfied, a requested change must also satisfy the following specific consistency requirements in order for a Participant to be able to alter his or her Election based on that change. (1) Loss of Dependent Eligibility. For a Change in Status involving a Participant’s divorce, annulment or legal separation from a Spouse, the death of a Spouse or a Dependent, or a Dependent ceasing to satisfy the eligibility requirements for coverage, a Participant may only elect to cancel accident or health insurance, or insurance type, coverage for the Spouse involved in the divorce, annulment, or legal separation, the deceased Spouse or Dependent, or the Depe ndent that ceased to satisfy the eligibility requirements. Canceling coverage for any other individual under these circumstances does not correspond with that Change in Status. (2) Gain of Coverage Eligibility Under Another Employer’s Plan. For a Change in Status in which a Participant, a Participant’s Spouse, or a Participant’s Dependent gains eligibility for coverage under another employer’s cafeteria plan (or another employer's qualified benefit plan) as a result of a change in marital status or a change in employment status, a Participant may elect to cease or decrease coverage only if that coverage becomes effective or is increased under the other employer’s plan. (3) Dependent Care Flexible Spending Account. With respect to the Dependent Care Flexible Spending Account, a Participant may change or terminate his or her Election only if (i) such a change or termination is made on account of and corresponds with a Change in Status that affects eligibility for coverage under the Plan; or (ii) the Election change is on account of and corresponds with a Change in Status that affects eligibility of depe ndent care expenses for the tax exclusion available under the Code. (4) Group Term Life Insurance and Disability Coverage. For a Change of Status involving a Participant’s legal marital status or the employment status of a Participant’s Spouse or Dependent (disregarding the requirement that the event cause a loss or gain of eligibility), a Participant may elect either to increase or to decrease group term life insurance or disability coverage (as defined in Treas. Reg. §1.125-4(i)(4)) offered under the Plan.