2012-09-26 CC Packet - Laserfiche WebLink

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(A) Participant and Eligibility Requirements The following eligibility requirements apply (choose all that are applicable). If a category is checked, but a maximum is not elected, it will be defaulted to the maximum. For a Standard FSA or POP: ❑ Part-time employees working at least hours per week will be included (maximum of 30 hours). ❑ Seasonal employees working at least months within a year will be included (maximum of 6 months). ❑ Employees reaching years of age will be included (maximum 21 years). Ig *Employees meeting Probationary period of lst months will be included (maximum 24 months). ❑ Members of bargaining unit will be included. For a SIMPLE FSA: All non - excludable employees with at least 1,000 hours of service during the preceding Plan Year must be eligible to participate in a SIMPLE Cafeteria Plan. Select the eligibility option(s) below for your Plan (choose all that are applicable). If a category is checked, but a maximum is not elected, it will be defaulted to the maximum. ❑ Employees reaching years of age before the end of the Plan Year will be included (maximum 21 years). ❑ Employees meeting the probationary period of month(s) will be included (maximum 12 months). ❑ Employees who are covered under a collective bargaining agreement will be excluded. ❑ Employees who are non - resident aliens will be excluded. After they have met the eligibility requirements above, an employee (other than a rehired employee) is able to enter and participate in the Plan on the first day of the Plan Year, or on such dates within the Plan Year noted: (i.e. January 1 and July 1). (B) SIMPLE FSA Employer Contribution Due to the complexity of the Matching Contribution method, the Uniform Contribution method is recommended and does not require a completed Addendum with your election. ❑ Uniform Contribution: A uniform percentage of employee compensation (at least 2 %), whether the employee does or does not make pre -tax salary reduction contributions to the Plan: % (defaults to 2% if left blank). ❑ Matching Contribution *: The lesser of 2x the amount of the pre -tax salary reduction contributions (including premiums) of each qualified employee, or 6% of the employee's compensation. ( *Matching Contribution Addendum required.) (C) Available Benefits Select the benefits available to the eligible employee(s). (Check all that apply.) These benefits are taken through salary deductions. ® *Medical or Medical - Related Premium - (Group Sponsored - Employee and Family) • Medical or Medical - Related Expense Reimbursement Account - ($ 2500.00 Maximum Election - Employee and Family) ® Dependent Care Reimbursement Account - (Annual Maximum $5,000; $2,500 if married filing separately - Employee and Family) ❑ Transportation Reimbursement Account - (Employee Only - Call for current monthly maximum) ❑ Voluntary/Group Term Life Insurance Premium - (Employee Only - Up to $50,000 in death benefits) ❑ Disability Insurance Premium - (Employee Only) - May eliminate pre -tax advantage of potential benefit payment. • Supplemental Insurance - (Employee and Family) - Includes cancer, hospital confinement, intensive care, accidental death and dismemberment. ® Individual Premium Reimbursement Account - Not offered through employer. (D) Plan Start ❑ Check if Mid -Plan Year takeover - If elected, please indicate current Plan Year dates under the current TPA. From: / / (mo /dd /yr) — To: / / (mo /dd /yr) Plan Number (3 digits): TASC first year administration shall begin on the first day of * (mo /yr) and continue for * consecutive months. For the second and successive years, the Plan shall operate starting on the first day of * (mo /yr) and continue for the following successive twelve (12) month period. Your first payroll deduction for FlexSystem administration will be taken on / / (mo /dd /yr). Note: Plans need not run on the calendar year (i.e. January 1- December 31). TC -3923- 080111 Employer Initial i , j , TASC 17