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© 2019 Hitesman & Wold, P.A. MEDSURETY, LLC Cafeteria Plan 1-888-816-4234, www.medsurety.com Basic Plan Document 16 (i) Special Rule for HSA Contribution Feature. A Participant may change his or her Election with respect to the HSA Contribution Feature prospectively on at least a monthly basis. A Participant may also revoke his or her Election w ith respect to the HSA Contribution Feature prospectively if the Participant becomes ineligible to make or have made HSA contributions under the HSA Contribution Feature. (j) Other. The Plan Administrator shall have the discretion to allow a change to or termination of an Election to the extent such change or termination is the result of any other situation informally recognized by the Internal Revenue Service as providing an exception to the general rule that Elections are irrevocable (e.g., corrections o f mistakes, changes to meet nondiscrimination requirements). A Participant entitled to make a new Election under this Section must do so within thirty (30) days of the event. An Employee who is eligible to elect benefits but declined to do so during the initial Election period, or during a subsequent Election period, may file a new Election within thirty (30) days of the occurrence of an event described above, but only if the new Election is made on account of and corresponds with the event. Subject to th e provisions of the underlying group health plan, Elections made to add medical coverage for a newborn or newly adopted Dependent child pursuant to a HIPAA special enrollment right may be retroactive for up to thirty (30) days. All other new Elections shall be effective prospectively immediately following the date the Participant files the new Election with the Plan Administrator. Elections made pursuant to this Section shall be effective for the balance of the Plan Year in which the Election is made unless a subsequent event (described above) allows a further Election change. 5.5 Rehire and Eligibility Loss. Termination of employment shall automatically revoke a ny Election. Former Participants who are rehired: (a) After thirty (30) days following a termination of employment, shall have two “periods of coverage;” that period prior to the termination of employment and that period following the re-employment of the terminated Employee. Expenses incurred prior to the termination of employment shall be subject to the Election in effect upon termination; while the Employee shall have an opportunity to make a new Election and expenses incurred after re-employment shall be subject to the Election made upon re-employment. (b) Within thirty (30) days following a termination of employment, shall have the Election in effect prior to the termination of employment reinstated upon re -employment. 5.6 Benefit Descriptions. Although an Election to pay for insurance and insurance-type Optional Benefits is made under this Plan, the benefits themselves will be provided in accordance with the documents or contracts describing the types and amounts of benefits available, the requirements for participation, the procedures for submitting claims, and the other terms and conditions of such coverage. Such underlying documents or contracts, if any, are incorporated into this Plan by reference. 5.7 Forfeiture. (a) Entities Subject to ERISA. Any amounts, whether obtained through salary reduction, salary deduction, Employer Contributions, or otherwise, unde r this Plan that are Plan assets and which cannot be distributed by the Plan Administrator to cover the cost of Optional Benefits for the applicable Plan Year, shall be forfeited by the Participant. The Plan Administrator may use such forfeited amounts to defray the reasonable administrative costs of the portion of the Plan yielding the forfeiture. To the extent forfeited amounts remain, the Plan Administrator shall arrange for the provision of a benefit for a broad cross section of Participants of the sa me type as the benefit which resulted in the forfeitures. Under no circumstances shall the Plan Administrator establish