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© 2019 Hitesman & Wold, P.A. MEDSURETY, LLC Cafeteria Plan 1-888-816-4234, www.medsurety.com Basic Plan Document 19 6.7 Reimbursement-Type Account Balances. Participants can obtain a statement of their account balances for the reimbursement-type accounts on the Claims Administrator’s website. 6.8 Claim for Benefits. This Section addresses the requirements for claims for reimbursement -type Optional Benefits offered under the Plan and the provisions of general applicability, regardless of whether the Optional Benefit is subject to ERISA. Claims require ments for other Optional Benefits shall be handled in accordance with the governing documents for those Optional Benefits. A Participant may apply to the Claims Administrator for reimbursement of eligible expenses incurred during such Plan Year (and applicable Grace Period) by submitting a paper claim, or, if provided in the Adoption Agreement, through electronic payment as described below: (a) Paper Claims. A Participant may make a claim by completing a claim form and submitting such form to the Claims Administrator via email, facsimile, mail, or the Claims Administrator’s website setting forth at least the following: (1) The amount, date and nature of the expense, including the identity of the individual who incurred the expense; (2) The name of the person or entity to which the expense was paid; (3) The Participant’s statement that the expense has not been reimbur sed and the Participant will not seek reimbursement for the expense; and (4) Such other information as the Claims Administrator may require. Such claim form shall be accompanied by such bills, invoices, receipts, explanations of benefits (“EOB”) issued by a health plan, or other statements from an independent third party as is necessary to establish that an eligible expense has been incurred and the amount of the expense. The Claims Administrator is entitled to rely on the information provided on the claim form in processing claims under this Plan. Where circumstances beyond the Participant’s control prevent submission within the described time frame, notice of a claim with an explanation of the circumstances may be accepted by the Claims Administrator as a timely filing. Claims shall be determined in accordance with Article VI. Reimbursement shall be made weekly or pursuant to a schedule established by the Pla n Administrator and Claims Administrator. Claims (including all information substantiating the claim) must be submitted by the deadline established and communicated by the Claims Administrator. Reimbursements shall be made from the Participant's respecti ve reimbursement-type account for eligible expenses incurred during the applicable Plan Year for which the Participant submits the required documentation. (b) Electronic Payment Cards – Health Flexible Spending Accounts. If provided in the Adoption Agreement, a Participant may receive reimbursement of an eligible expense under the Health Flexible Spending Account and the Limited Scope Health Flexible Spending Account (as applicable) by use of an electronic payment card at the time the eligible expense is incurred. A Participant must elect to use the electronic payment card, and must agree to abide by the terms and conditions of the electronic payment card program as set forth in a separate agreement with the electronic payment card provider. If required, Participants must execute a new agreement prior to the start of each Plan Year. In addition to the terms and conditions of the electronic payment card program, the use of the electronic payment card shall be subject to the following conditions: