2007-12-12 CC Packet - Laserfiche WebLink

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Health Savings Account (HSA) Administrative Services Agreement This Administrative Services Agreement is entered into this _ day of _,20_ by and between Wels Fargo Bank, N.A. (Wells Fargo) and _ (Employer). \l\lHEREAS, Employer intends to offer fts employees a high deductible heaith plan and to make available to Is employees health savings acoounts described in section 223 of the Internal Revenue Code (HSAs), to which it may make contributions, including deferral contributions from its employees' salary, from time to time: and \l\lHEREAS, Wells Fargo, a national banking assooiation is qualified to act as the trustee of HSAs as defined in section 223(d)(1 )(8) of the Internal Revenue Code, provides trustee and administrative services to HSAs: and \l\lHEREAS, Wells Fargo will act as Trustee for HSA Plans offered to the HSA Owner and provide related services to the Employer for purposes offunding or providing HSA Plans to their employees: and \l\lHEREAS, Employer desires to engage the services of Wells Fargo to provide such services and Wells Fargo desires to provide such services. NOW THEREFORE, for and in consideration of their mutual promises herein contained and other valuable consideration, the parties covenant and agree as follows: 1. Wells Fargo's Duties. Service provider shall: 1.1 Open and maintain an HSA in the name of the Trustee for the benefrtofthe HSAOwner. 1.2 Accept HSA contributions from employer and HSA Owner, including transfers from other fmancial institutions, up to the maximum amount anowed by law. 1.3 Hold in the HSA aD cash contributed and gains and losses attributable thereto for the exclusive purpose of paying qualified medical expenses of the HSA Owner pursuant to the provisions of section 223 ofthe Internal Revenue Code. 1.3 Act upon the written directions of the HSA Owner, including sett6ng investment transactions and making distributions from the HSA, provided that directions given in electronic form shaD be treated as written directions. 1.4 Maintain HSA Owner records reflecting an inventory of the assets of each HSA Acoount, all activity transacted during the previous year and a mamet value of tha assets of the HSA Acoount. 1.5 Prepare and deUver reports, including a report, setting forth the fair market value of the HSA Account, together with particulars of purchases, sales, receipts, income, loss, and other transactions, and customary confirmations whenever transactions occur, or as othelVl.4se required by laW; provided that such reports may be delivered electronically to the extend permitted by law and agreed upon by the parties. 1.6 Take direction from the HSA Owner with respect to the voting or tender of proxy materials. 1,7 Preparetaxfeporting withrespecl to oontribulions and distribulionsas JeqUired by thelntemal Revenue Code and applicable Jaw (Forms 5498-SA and1099-SA). 1.8 Provide copies of an HSA governing instrument to HSA Owners, together with disclosures as required by law (HSA Plan) and maintain the HSA Plan in compliance with applicable law. 1.9 Provide and servica debit cards or stored-value cards as permitted by law. 2. Powers of Wells Fargo. The service provider is authorized and empowered to: 2.1 Receive and rely upon payron and allocation data from the Employer. 2.2 Hold assets in its own name or the name of a nominee for the exclusive benefrt of the HSA Owner. 2.3 Make, execute, acknowledge, and deliver any and aD documents of transfer and conveyance and any other instruments that may be necessary or appropriate to carry out the Trustee duties and powers. 2.4 At the direction of the HSA Owner, invest the HSA Account in mutual funds, including mutual funds for which it provides services, including investment advisory services and receives compensation, as disclosed to the Employer and HSA Owner. 3. Employer Duties. Employer shall: 3.1 Provide Service Provider information regarding each employee who establishes an HSA as required by law. 3.2 Promptly remit contributions, including salary deferral contributions, and allocation Instructions as required by law and agreed by the parties. 3.3 Provide Service Provider information regarding termination of employment and expiration of COBRA coverage. 4. Reports. Service Provider shan furnish to Employer within 30 days aller the end of the year, or as otherwise agreed, such service reports as the parties mutually agree. 5. Fees. In consideration for Is services, Service Provider shall receive compensation a6 set below. Such fees shall be paid by the Employer, but to the extent not paid by the Employer by the HSA Owner or the HSA, as mutually agreed by the parties. To the extentlhat such fees are paid by the HSA Owner or the HSA, they shall be fully disclosed in advance to the HSA Owner. The monthly administrative fee is $4.25. This fee includes claim payment, reimbursements to participants via check or ACH, reports to the participants and the employer, and Investments using the OmniPlus system. These fees also include the Wells Fargo HSA deb. card. 6. Authorized Representatives. Employer shan furnish a list to the Service Provider (which list shan be amended time to time as changes occur) of persons authorized to act on behalf of Employer for the purpose of transmitting contributions and instructions to the Service Provider. 7. Distributions. At the direction of the HSA Owner, Service Provider shan make distributions in the form designated by the HSA Owner and permitted by the HSA Plan. 8. Inquiries and Requests. Service Provider shall designate a contact to be responsible for responding to all inquiries and requests made by HSA Owners or by the Employer with respect to HSAs. HSA AdmInistrative Agreement Page 1 !;;)