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HomeMy WebLinkAbout2012-09-26 CC Packet CITY OF CENTERVILLE COUNCIL MEETING & EXECUTIVE SESSION AGENDA tervi[(.e Wednesday, September 26, 2012 Esta6 fulled 1857 6:30 p.m. or shortly thereafter w/Executive Session following Regular Meeting OPEN FORUM 6:30 p.m.: An opportunity for members of the public to address the City Council on items not on the current agenda. Items requiring Council action may be deferred to staff or Boards and Commissions for research and future Council Agendas if appropriate. You will be limited to two (2) minutes and we ask that you conduct yourself in a professional, courteous manner, and refrain from the use of profanity. Failure to abide by this policy may result in the loss of your privilege to speak. Persons wishing to speak will be required to complete a sign -up sheet and give it to the Mayor or a Staff person by 6:15 p.m. COUNCIL MEETING I. CALL TO ORDER 1. Roll Call II. PUBLIC HEARING(S) III. APPROVAL OF AGENDA IV. APPROVAL OF MINUTES 1. September 26, 2012 City Council Meeting & Work Session Meeting Minutes (Pages 1 -7) V. CONSENT AGENDA 1. City of Centerville September 13, 2012 through September 26, 2012 Claims (Check #27431 - 27470) (Pages 8 -9) 2. Centennial Police Department Claims through September 13, 2012 (Check #9098 -9117) (Page 10) 3. Centennial Fire District Claims through September 7, 2012 (Check #5481- 5507) w /Check #5453 -5457 Payroll (Page 11) 4. Encroachment Agreement — 7185 Brian Drive — Fence (Page 12) 5. Centerville Lions Annual Haunted House — Special Event Permit (Page 13) VI. AWARDS /PRESENTATIONS /APPEARANCES 1. Mr. Hal Leibel and Mr. John Vondelinde - Proposed Sale of Parcel by Leibel to Anoka County Parks (Page 14) VII. OLD BUSINESS 1. None VIII. NEW BUSINESS 1. Approve Agreement with TASC for Assistance with Administering Flexible Benefit Plan. (Substitute for prior administrator AFLAC) (Pages 15 -29) 2. Approval of Contract with Union Local 49, Public Works Employees (Page 30) IX. ANNOUNCEMENTS/UPDATES 1. City Administrator Larson a. Liquor License Renewal Has Started X. CLOSED EXECUTIVE SESSION 1. Purchase /Sale of Real Estate XI. ADJOURNMENT *REMINDERS ** In- Person Absentee Voting — September 21 — November 5, 2012 City Hall City Council Meeting — September 26, 2012, 6:30 p.m. Council Chambers Skate Night — September 29, 2012, 5:30 p.m., Schwan Super Rink Planning & Zoning Commission Meeting — October 2, 2012, 6:30 p.m. Council Chambers Parks & Recreation Committee Meeting — October 3, 2012, 6:30 p.m. @ Hidden Spring Park City Council Meeting — October 10, 2012, 6:30 p.m. Council Chambers Centerville Lions Haunted House — October 19, 20 & 26 & 27, 2012, 5:00 p.m. — 11:00 p.m. @ LaMotte Park Warming House, 6970 LaMotte Drive — PENDING APPROVAL General Election — November 6, 2012, 7:00 a.m. — 8:00 p.m. — St. Gen's Community Center, 6995 Centerville Road CITY OF CENTERVILLE CITY COUNCIL MEETING September 12, 2012 6:30 p.m. Pursuant to due call and notice thereof, the City of Centerville held their regularly scheduled meeting of September 12, 2012 at City Hall, 1880 Main Street. PRESENT: Mayor Tom Wilharber Council Member Ben Fehrenbacher Council Member Steve King ; 0 Council Member D. Love Member Jeff Paar p ( y R ABSENT: None STAFF: City Administrator Dallas Larson City Engineer Mark Statz Legal Counsel Kurt Glaser Public Works Director/Building Official Paul Palzer Finance Director Mike Jeziorski I. CALL TO ORDER Mayor Wilharber called the meeting to order at 6:33 p.m. II. PUBLIC HEARING(S) None. III. APPROVAL OF AGENDA Mayor Wilharber requested that an item be added under New Business, Item #4 — New Business Development Prospect. Mayor Wilharber stated that Check #27471 — 27474 should be added to the agenda. Motion by Council Member Paar, seconded by Council Member Love to approved the Set Agenda as presented. All in favor. Motion passed unanimously. IV. APPROVAL OF MINUTES 1. August 15, 2012 City Council Work Session Meeting Minutes * *Tabled from Previous Meeting ** 1 City of Centerville Council Meeting Minutes September 12, 2012 Motion by Council Member Fehrenbacher, seconded by Council Member Paar to approve the presented August 15, 2012 City Council Work Session Meeting Minutes. All in favor. Motion passed unanimously. 2. August 22, 2012 City Council Meeting Minutes Motion by Council Member Love, seconded by Council Member King to approve the presented August 22, 2012 City Council Meeting Minutes. Discussion: Council Member Fehrenbacher stated that he was listed as being present and absent. Council Member Fehrenbacher was absent from the meeting. A friendly amendment to the motion was made to modify the meeting minutes to reflect that Council Member Fehrenbacher was not present at the August 22, 2012 Council Meeting. Council Member Fehrenbacher abstained. Motion passed. 3. August 22, 2012 City Council Work Session Meeting Minutes Motion by Council Member Paar, seconded by Council Member King to approve the presented August 22, 2012 City Council Work Session Meeting Minutes. Council Member Fehrenbacher abstained. Motion passed. V. CONSENT AGENDA 1. City of Centerville August 23, 2012 through September 12, 2012 Claims (Check #27432 -27470 & Check #27471- 27474) 2. Centennial Police Department Claims through August 23, 2012 (Check #9079- 9097) 3. Centennial Fire District Claims through August 16, 2012 (Check #5458 -5480) w /Check #5453 -5457 Payroll 4. Res. #12 -0XX — Proclamation Resolution — Constitution Week (September 17 -23, 2012 5. Successful Performance Evaluation, Mr. Greg Burmeister, Lead Project Coordinator, Step 9, Grade 6 6. Mediation Services Agreement for 2013 — Not to Exceed $417 Council Member King removed Item #6 for discussion. Council Member King questioned whether mediation was offered to the residents at 7121 Centerville Road. Administrator Larson stated that there was no reason to offer this service to them because Page 2 of 7 2 City of Centerville Council Meeting Minutes September 12, 2012 there was no dispute regarding what had to be done, they just did not perform as promised. Council Member King withdrew his request. Motion by Council Member Love, seconded by Council Member Fehrenbacher to approve the consent agenda as presented. All in favor. Motion passed unanimously. VI. AWARDS /PRESENTATIONS /APPEARANCES None. VII. OLD BUSINESS None VIII. NEW BUSINESS 1. 2013 Budget & Levy a. Res. #12 -021 — Approving Proposed 2013 Budget & Preliminary Tax Levy Finance Director Jeziorski reviewed fund balances forecasted through the end of the year, anticipated fund balances for the upcoming year, the levy remaining the same for 2013 and the process for forwarding the preliminary budget information to the County for preliminary tax statements being forwarded to taxpayers in November. Administrator Larson stated that at the last work session discussions ensued regarding equipment, equipment purchases and replacement of same along with capital outlay items such as a new roof on the Public Works Building and Fire Hall, replacement of carpeting at City Hall, etc. Administrator Larson stated that these items had been taken into account within the budgeting process and that sufficient money is budgeted for 2013, but the same amount should continue each year. Director Jeziorski stated that equipment purchases /replacement and capital outlay long term planning had not been adequately funded in past years. Council Members felt that this was very encouraging and would avoid significant budget increases due to major equipment replacements. Director Jeziorski stated that the City meets the legal requirements for reserve amounts. Lengthy discussion was had regarding Market Value Homestead Credit and Local Government Aid programs. Council Members requested additional information to be provided by Director Jeziorski at their December budget hearing such as percentage of Page 3 of 7 3 City of Centerville Council Meeting Minutes September 12, 2012 the City's budget being funded by residential property owners versus commercial /industrial property owners and the affect on individual households. Motion by Council Member Paar, seconded by Council Member Love to adopt Res. #12-021 — Approving Proposed 2013 Budget & Preliminary Tax Levy as presented. All in favor. Motion passed unanimously. 2. Snowplowing Policy Administrator Larson stated that the City has had a snow plowing policy for many years; however, it was time for updating the policy and procedures with the addition of a map including the plow routes with priorities. Administrator Larson stated that he had worked closely with Staff regarding the policy and it ensures safe passage to major thoroughfares with at least a plow width to commence the process and then later clearing of the entire roadway. Plowing would commence upon 2 -3 inches of snowfall. Staff was also given the authority to deviate from the policy from time to time to ensure public safety. Motion by Council Member Fehrenbacher, seconded by Council Member Love to approve the presented Snowplowing Policy. Discussion: Council Member Fehrenbacher requested that the presented policy be forwarded to the Police Chief and questioned whether Mr. Palzer was comfortable with the policy. Mr. Palzer concurred. All in favor. Motion passed unanimously. 3. Soil Removal — Ditch Cleaning a. L.N. Sodding, LLC - $11,000 b. Olson's Sewer Service, Inc. - $5,022 (est.) & $1,716 Ditch Cleaning Administrator Larson reported that the work that had been completed by Staff has provided residents with ample drainage; however, spoilage has been left behind in the easements to dry and residents are dissatisfied due to the odor and nuisance of the piles. Administrator Larson stated that with the recent resignation of a public works employee and another employee out on leave the City has been unable to complete the project. It is the recommendation of Staff to hire a contractor to complete the ditch work and dispose of the spoilage. Motion by Council Member Fehrenbacher, seconded by Council Member King to award the ditch cleaning project to Olson's Sewer Service, Inc. in an amount not to exceed $7,000 Page 4 of 7 4 City of Centerville Council Meeting Minutes September 12, 2012 Discussion: Council Member Paar questioned the fund availability. Director Jeziorski stated that the Storm Fund would be utilized and that funding was available for this project. All in favor. Motion passed unanimously. 4. Business Development Prospect Administrator Larson stated that he had been in contact with a business that would be interested in a commercial site of 2 -3 acres for an 11,000 square foot building allowing for future expansion to 30,000 square feet. The business stated that a neighboring community had offered a free building site for the business; however, this had yet to be confirmed. Administrator Larson stated that the City does not have property available within their new development along Commerce Drive unless two lots were utilized. Administrator Larson brought this discussion before Council to ascertain whether Council desired to offer Tax Increment Financing or other incentives to attract the business to Centerville. A potential site was discussed; however, soil borings would need to be completed to determine whether the site is viable and the site is currently not owned by the City. Consensus of the Council was to have the Administrator continue discussions with the current land owner and the potential business owner; however, support for tax increment financing would be limited to about 8 years. IX. ANNOUNCEMENTS/UPDATES Administrator Larson reported that the Anoka County Parks and Recreation Department desires to purchase a vacated business which contains Indian burial mounds. Lengthy discussion was had regarding the property becoming public property and being removed from the tax rolls. However, the County is willing to provide the City with an easement for an entrance monument and a one -time payment in -lieu of removing the property from the tax roll. Consensus of the Council was not to support the proposal by Anoka County for this purchase. Administrator Larson reported that the City would begin cleanup efforts regarding the property in the downtown area shortly. A contractor, Building Official Palzer, Police Department and Attorney Glaser will all be on hand. Mayor Wilharber reported that on Tuesday, September 11, 2012 the Anoka County Commissioners had held a meeting at Centerville and he was on hand to greet them and to learn that they will be decreasing their levy for 2013. Mayor Wilharber reported that the County will be holding a meeting to discuss reconstruction of Centerville Road Page 5 of 7 5 City of Centerville Council Meeting Minutes September 12, 2012 (CSAH 21). Mayor Wilharber reported that the County anticipated holding an open house in November to discuss the construction with abutting property owners. Council Member King stated that the Parks and Recreation Committee had numerous questions associated with the appointment of two (2) members to the Committee making the Committee eight (8) members rather than seven (7), voting and quorum requirements. Council Member King requested that Administrator Larson speak with the Chair regarding these matters. Recess at 8:05 p.m. for a five (5) minute break prior to entering the Closed Executive Session. X. CLOSED EXECUTIVE SESSION All members of Council were present along with Administrator Larson and Attorney Glaser. 1. Labor Negotiations with Local 49'ers Administrator Larson reported that a mediation session is scheduled for the coming week and reviewed the positions of both the City and the Union members. Council provided guidance for the mediation session. XI. REOPEN REGULAR SESSION Council reopened the meeting to the public at 8:32 p.m. It was noted that the only issue of discussion during the closed portion of the meeting was labor negotiation issues. Council considered a proposed resolution setting pay and benefits for non -union Staff for 2012 -2014. 1. Consider Res. #12 -022 — Adjusting Compensation for Non - Bargaining Unit Employees Motion by Council Member Fehrenbacher, seconded by Council Member Love to adopt Res. #12 -022 — Adjusting Compensation for Non - Bargaining Unit Employees as presented. All in favor. Motion passed unanimously. Page 6 of 7 6 City of Centerville Council Meeting Minutes September 12, 2012 XII. ADJOURNMENT Motion by Council Member Paar, seconded by Council Member Fehrenbacher to adjourn the September 12, 2012 City Council Meeting at 8:35 p.m. All in favor. Motion passed unanimously. Council Meeting Minutes Transcribed by: Teresa Bender, City Clerk Closed Executive Session Transcribed by: Dallas Larson, City Administrator Page 7 of 7 7 CITY OF CENTERVILLE 09/20/12 10:34 AM Page 1 Check Detail - September 26, 2012 Check Date Check # Vender Name Comments Amount 9/26/2012 027475 ANOKA COUNTY PARKS 8k RUN /WALK/IN -LINE SKATE - SPECIAL EVENT PERMIT Check Nbr 027475 ANOKA COUNTY PARKS $187.47 9/26/2012 027476 CITY OF ST. PAUL ASPHALT Check Nbr 027476 CITY OF ST. PAUL $1,591.95 9/26/2012 027477 COMCAST 1880 MAIN ST - HIGH SPEED INTERNET Check Nbr 027477 COMCAST $24.40 9/26/2012 027478 DELTA DENTAL PF99867701 - OCT. 2012 DENTAL INS. $334.50 9/26/2012 027478 DELTA DENTAL PF99867701 - OCT. 2012 COBRA - K. STEPHAN $29.20 Check Nbr 027478 DELTA DENTAL $363.70 9/26/2012 027479 E.G. RUD & SONS 2044 WILLOW CIRCLE - GRADING & UTILITY AS BUILT Check Nbr 027479 E.G. RUD & SONS $440.00 9/26/2012 027480 GOETZ LANDSCAPE & IRRIG. LAWN MOWING SERVICE $1,932.78 9/26/2012 027480 GOETZ LANDSCAPE & IRRIG. LAWN MOWING SERVICE $28.64 9/26/2012 027480 GOEIL LANDSCAPE & IRRIG. LAWN MOWING SERVICE $134.32 Check Nbr 027480 GOETZ LANDSCAPE & IRRIG. $2,095.74 9/26/2012 027481 INSTRUMENTAL RESEARCH INC AUGUST 2012 WATER TEST Check Nbr 027481 INSTRUMENTAL RESEARCH INC $38.00 9/26/2012 027482 INTERNATIONAL UNION OF OPERATI OCT. 2012 UNION DUES Check Nbr 027482 INTERNATIONAL UNION OF OPERATI $65.00 9/26/2012 027483 JEZIORSKI, MIKE MILEAGE REIMBURSEMENT Check Nbr 027483 JEZIORSKI, MIKE $13.32 9/26/2012 027484 MET. COUNCIL ENV. SERV. (SDS) OCT. 2012 WASTEWATER SERVICE Check Nbr 027484 MET. COUNCIL ENV. SERV. (SDS) $15,769.71 9/26/2012 027485 NAGELL APPRAISAL & CONSULTING 2013 IMPR. STREET & STORM SEWER IMPROV. PROJ Check Nbr 027485 NAGELL APPRAISAL & CONSULTING $1,101 9/26/2012 027486 OLSON SEWER SERVICE, INC. 2044 GATEWAY CIR - GATE VALVE BOX W /COVER & CURB $952. 9/26/2012 027486 OLSON SEWER SERVICE, INC. 7029 CENTERVILLE RD - EXCATION WORK TO CHECK ON $765.00 Check Nbr 027486 OLSON SEWER SERVICE, INC. $1,717.72 9/26/2012 027487 PALZER, PAUL MILEAGE REIMBURSEMENT Check Nbr 027487 PALZER, PAUL $91.57 9/26/2012 027488 PETERSON, TEDD MILEAGE REIMBURSEMENT - WATER TRAINING Check Nbr 027488 PETERSON, TEDD $66.60 9/26/2012 027489 REGENCY HOMES, INC. 6732 BEAVER POND WAY - PARTIAL ESCROW RELEASE Check Nbr 027489 REGENCY HOMES, INC. $4,000.00 9/26/2012 027490 RIVARD ELECTRIC COMPANY INC REPAIR LIGHTING AT HIDDEN SPRINGS PARK Check Nbr 027490 RIVARD ELECTRIC COMPANY INC $371.00 9/26/2012 027491 SEH 2012 GIS SERVICES Check Nbr 027491 SEH $153.75 9/26/2012 027492 TASC FLEX SYSTEM ADMINISTRATOR 2.heck Nbr 027492 TASC $275.00 9/26/2012 027493 VERIZION WIRELESS CELL PHONE SERV THRU 9 -2012 $43.28 9/26/2012 027493 VERIZION WIRELESS CELL PHONE SERV THRU 9 -2012 $43.28 9/26/2012 027493 VERIZION WIRELESS CELL PHONE SERV THRU 9 -2012 $129.86 9/26/2012 027493 VERIZION WIRELESS CELL PHONE SERV THRU 9 -2012 $43.28 9/26/2012 027493 VERIZION WIRELESS CELL PHONE SERV THRU 9 -2012 $43.28 :heck Nbr 027493 VERIZION WIRELESS $302.98 8 1.1 1 Y Vr I•CIV 1 C1 V ILLC 09/20/12 10:34 AM Page 2 Check Detail - September 26, 2012 Check Date Check # Vender Name Comments Amount 9/26/2012 027494 XCEL ENERGY 1600 LAMOTTE DR- BALL FIELD LIGHTS - SERV THRU 9 -4 -12 $9.88 9/26/2012 027494 XCEL ENERGY 1880 MAIN ST - SERV THRU 9 -4 -12 $1,835.29 9/26/2012 027494 XCEL ENERGY 7285 MAIN ST - SERV THRU 9 -4 -12 $55.73 9/26/2012 027494 XCEL ENERGY 1889 CENTER ST- SEWER LIFT - SERV THRU 94 -12 $15.43 9/26/2012 027494 XCEL ENERGY 7300 MILL RD - SERV THRU 9 -4 -12 $126.55 9/26/2012 027494 XCEL ENERGY 1600 LAMOTTE DR - WARMING HOUSE - SERV THRU 9 -4 -12 $9.90 9/26/2012 027494 XCEL ENERGY 1875 FOX RUN - SERV THRU 9 -4 -12 $89.89 9/26/2012 027494 XCEL ENERGY STREET - SERV THRU 9 -4 -12 $2,351.43 9/26/2012 027494 XCEL ENERGY 1601 LAMOTTE DR - SERV THRU 9 -4 -12 $40.13 9/26/2012 027494 XCEL ENERGY 7098 CENTERVILLE RD - SERV THRU 9 -4 -12 $9.90 9/26/2012 027494 XCEL ENERGY 1745 MAIN ST - SERV THRU 9 -4 -12 $9.48 9/26/2012 027494 XCEL ENERGY 1682 MAIN ST - SERV THRU 9 -4 -12 $9.48 9/26/2012 027494 XCEL ENERGY 6970 LAMOTTE DR - SERV THRU 9 -4 -12 $239.63 9/26/2012 027494 XCEL ENERGY 1880 MAIN ST - CJTYHALL /FIRE STAT - SERV THRU 9 -4 -12 $534.60 Check Nbr 027494 XCEL ENERGY $5,337.32 9/26/2012 027495 NATIONWIDE RETIREMENT SOLUTION DEF COMP PAY PERIOD 20 Check Nbr 027495 NATIONWIDE RETIREMENT SOLUTION $160.00 TOTAL CHECKS $34,165.23 9 CENTENNIAL LAKES POLICE DEPT Check Register - Police GL without invoice numbers Page: 1 Check Issue Dates: 9/1/2012 - 9/13/2012 Sep 13, 2012 04:19PM Report Criteria: Report type: Summary GL Check Ck No Description Check Period Issue Date Payee Amount 09/12 09/13/2012 9098 ANOKA COUNTY RADIO ANTENNA 26.27 09/12 09/13/2012 9099 ASPEN MILLS, INC UNFORMS 295.82 09/12 09/13/2012 9100 CENTENNIAL UTILITIES AUG UTILITIES 534.06 09/12 09/13/2012 9101 CENTURY LINK CENTERVILLE PHONE 170.88 09/12 09/13/2012 9102 CITY OF CENTERVILLE FORFEITURE PROCEEDS HARLEY 779.40 09/12 09/13/2012 9103 COVERALL OF TWIN CITIES, INC SEPT CLEANING SERVICES 2,746.70 09/12 09/13/2012 9104 DON'S CIRCLE SERVICE, INC VEH REPAIRS & MTC 1,877.00 09/12 09/13/2012 9105 ENVENTIS TELECOM, INC PHONES & LONG DISTANCE 402.25 09/12 09/13/2012 9106 FRATTALLONES HARDWARE, INC. PHOTO BATTERIES 80.19 09/12 09/13/2012 9107 HOLIDAY FLEET AUGUST FUEL 4,723.70 09/12 09/13/2012 9108 JFB DESKTOP PUBLISHING EQUIPMENT MTC 102.50 09/12 09/13/2012 9109 KEEPRS, INC FIREARM EQUIPMENT 7,234.35 09/12 09/13/2012 9110 KNOWLAN'S SUPER MARKETS SUPPLIES AUSTIN FAREWELL 50.67 09/12 09/13/2012 9111 CITY OF LEXINGTON 99 RANGER FORFEITURE PROCEEDS 126.09 09/12 09/13/2012 9112 NE WISCONSIN TECH COLLEGE TRAINING M.LANGRECK 175.00 09/12 09/13/2012 9113 QUILL CORPORATION OFFICE SUPPLIES 197.04 09/12 09/13/2012 9114 SAFELITE FULFILLMENT, INC 2011 FORD GLASS REPL 185.25 09/12 09/13/2012 9115 SUN LIFE FINANCIAL SEPT LIFE /DISABILITY 74.80 09/12 09/13/2012 9116 TELECIDE PRODUCTIONS, INC COMPUTER MTC /SUPPORT 722.08 09/12 09/13/2012 9117 TIRE KINGDOM, INC 18 TIRES 2,516.97 Grand Totals: 23,021.02 M = Manual Check, V = Void Check 10 CENTENNIAL FIRE DISTRICT Check Register - FIRE GL Page: 1 Check Issue Dates: 9/1/2012 - 9/7/2012 Sep 07, 2012 02:27PM .eport Criteria: Report type: Summary GL Check Check Vendor Description Check Period Issue Date Number Number Payee Amount 09/12 09/07/2012 5481 10600 ANCOM COMMUNICATIONS, IN RADIO INSTALL C -1 418.11 09/12 09/07/2012 5482 10785 ANOKA COUNTY FIRE ACADEM 8 STUDENTS FIREFIGHTER TR 6,800.00 09/12 09/07/2012 5483 11565 ASPEN MILLS, INC UNIFORM 771.74 09/12 09/07/2012 5484 30490 CENTERPOINT ENERGY STATION 2 GAS 31.24 09/12 09/07/2012 5485 30500 CENTURY LINK CENTERVILLE PHONE 57.31 09/12 09/07/2012 5486 31008 COMCAST INTERNET CENTERVILLE STATI 203.00 09/12 09/07/2012 5487 31505 COON RAPIDS FIRE DEPT ANNUAL MTC SHARE POSI TES 416.66 09/12 09/07/2012 5488 60115 FAIRVIEW PHARMACY SERVIC MEDICAL SUPPLIES - EPIPENS 572.84 09/12 09/07/2012 5489 70578 GRAINGER 3 PAIR FIRE BOOTS 1,129.56 09/12 09/07/2012 5490 70600 GREAT AMERICAN MARINE INC REPAIR OLD BOAT 359.16 09/12 09/07/2012 5491 110250 BRIAN KINDELBERGER CLEANING SUPPLY 28.90 09/12 09/07/2012 5492 110300 KIRVIDA FIRE, INC 1995 FREIGHTLINER MTC 307.50 09/12 09/07/2012 5493 120390 LEGEND DATA SYSTEMS, INC NAME TAGS 32.90 09/12 09/07/2012 5494 120450 CITY OF LINO LAKES JULY REIMBURSEMENTS 26,024.57 09/12 09/07/2012 5495 130297 MARTIN - MCALLISTER CONSUL PUBLIC SAFETY ASSESSMENT 800.00 09/12 09/07/2012 5496 130440 METRO FIRE, INC SCBA PARTS 1,165.16 09/12 09/07/2012 5497 130850 MN FIRE CHIEFS ASSOC. CONFERENCE /MP 210.00 09/12 09/07/2012 5498 140050 NFPA NATL FIRE CODES SUBSCRIPTI 950.00 09/12 09/07/2012 5499 160050 PAETEC PHONES STATION 2 150.46 09/12 09/07/2012 5500 160130 PERFORMANCE PLUS LLC PREPLACEMENT MEDICAL TES 593.00 09/12 09/07/2012 5501 160300 PHYSIO - CONTROL, INC MEDICAL SUPPLIES AED 124.76 09/12 09/07/2012 5502 180500 RANDY ROLSTAD FIRE PREVENTION SUPPLIES 115.27 09/12 09/07/2012 5503 180600 CITY OF ROSEVILLE SEPT PHONE SERVICE 839.16 09/12 09/07/2012 5504 190500 SIGNS NOW VINYL NAMES FOR HELMETS 54.19 09/12 09/07/2012 5505 190850 JERRY STREICH PARKING REIMB 190.00 09/12 09/07/2012 5506 210232 UNI- SELECT VEH PARTS 142.76 09/12 09/07/2012 5507 220200 VERIZON WIRELESS COMMUNICATIONS 78.27 Grand Totals: 42,566.52 M = Manual Check, V = Void Check 11 TO: Honorable Mayor and Council Members FROM: Staff SUBJECT: Encroachment Agreement — 7185 Brian Drive — Fence DATE: September 14, 2012 Property owners have submitted the appropriate permit application, sketch plan, agreements, signatures and fees for the permit and agreement. The Building Official has signed off on the permit and the location of the item. 12 TO: Honorable Mayor & Council Members FROM: Staff SUBJECT: Centerville Lions Request for Special Event Permit — Annual Haunted House/Use of 6970 LaMotte Drive Warming House DATE: September 21, 2012 The Centerville Lions have submitted the appropriate documents associated with the event; however, no other entities or departments have had an opportunity to review, approve or deny. This is an annual event that has been offered by them for many years with use of the City's warming house. Recommendation would be to approve the Special Event Permit subject to all entities (FD, PD & Electrical Inspection) and department's approval (P & R and Building Inspections). 13 Anoka County PROPERTY TAX Larry W. Dalien, Division Manager 2013 STATEMENT Property Records and Taxation 2100 3rd Avenue Anoka, MN 55303 -2281 (763) 323 -5400 PROPERTY TAX VALUES & CLASSIFICATION www.co.anoka.mn.us Taxes Payable Year: 2012 2013 Estimated Market Value: 214,300 190,200 Taxpayer(s): LEIBEL HALL & PAMELA K 7566 PELTIER LAKE DR LINO LAKES MN 55038 -0000 Taxable Market Value: 214,300 190,200 New Improvements/ Expired Exclusions: Property I.D.: 15 -31 -22-43 -0003 REAL Property Classification: Comm/Ind Comm/Ind Property Description: THAT PRT OF LOT 7 AUD SUB NO 46 REV DESC AS FOL, COM AT A PT IN THE E LINE OF GOVT LOT 5 SEC 15 -31 -22 DIST 233.17 FT S OF THE NE COR OF SD GOVT LOT 5 (SD E LINE OF GOVT LOT 5 BEARS S 0 DEG 21 MIN 37 S 7397 MAIN ST You may be eligible for one or even two CENTERVILI E MN 55038 - 0000 refunds to reduce your property tax. TCA:28012B Acres: 1.34 Owner(s): LEIBEL HALL & PAMELA K REFUNDS? Read the back of this statement to find out how to apply. Taxes Payable Year: 2012 2013 1. Use this amount on Form M 1 PR to see if you are eligible for a property tax refund. $0.00 File by August 15. If this box is checked you owe delinquent taxes and are not eligible. El 2. Use these amounts on Form M 1 PR to see if you are eligible for a special refund. $0.00 Property Tax and Credits 3. Property taxes before credits $7,596.07 $0.00 4. Credits that reduce property taxes A. Agricultural market value credit $0.00 $0.00 B. Other credits $0.00 $0.00 5. Property taxes after credits $7,596.07 $0.00 Property Tax by Jurisdiction 6. County: A. General county levy $849.26 50.00 B. Regional rail authority 513.42 50.00 7. County /municipal public safety radio system $9.68 50.00 8. City or town 51,378.64 50.00 9. State general tax $1,806.90 50.00 A. Voter approved levies $915.42 $0.00 B. Other local levies $383.56 50.00 11. Special taxing districts: A. Metropolitan special taxing districts 567.36 50.00 B. Other special taxing districts 582.40 50.00 C. Tax increment 50.00 $0.00 D. Fiscal disparity $2,089.43 50.00 12. Non - school voter approved referenda levies $0.00 50.00 13. Total property tax before special assessments $7,596.07 50.00 Special Assessments 14. Special assessments: A. Solid waste management charge $53.23 50.00 B. All other special assessments $0.00 $0.00 C. Contamination tax $0.00 50.00 15. TOTAL PROPERTY TAX AND SPECIAL ASSESSMENTS 57,649.30 50.00 Pay this amount no later than $0.00 Pay this amount no later than $0.00 2nd HALF PAYMENT STUB - PAl'ABLE 2013 1st HALF PAYMENT STUB - PAYABLE 2013 To avoid penalty, pay on or before To avoid penalty, pay on or before If your tax is $100.00 or less, pay the entire tax by . Taxpayer(s): LEIBEL HALL & PAMELA K Taxpayer(s): LEIBEL HALL & PAMELA K 7566 PELTIER LAKE DR 7566 PELTIER LAKE DR LINO LAKES MN 55038 -0000 LINO LAKES MN 55038 -0000 Property LD.: 15 -31 -22-43 -0003 REAL Property I.D.: 15- 31- 2243-0003 REAL Total Property Tax for 2013: 50.00 Total Property Tax for 2013: 50.00 Second -half payment: 50.00 First -half payment: 50.00 Please Include Property I.D. on Check Please Include Property LD. on Check Make Check Payable To: Anoka County Make Check Payable To: Anoka County 2100 3rd Ave., ANOKA, MN 55303 2100 3rd Ave., ANOKA, MN 55303 15- 31 -22 -43 -0003 000000000.00 15- 31 -22 -43 -0003 000000000.00 15- 31 -22 -43 -0003 000000000.00 Your canceled check is your receipt. Do not send cash. I I Your canceled check is your receipt. Do not send cash. Check to indicate address corrections on back 1 • Check to indicate address corrections on back 14 Group Services Plan Application �.. ICI! p PP Please submit your completed Plan Application with enrollment fee to: E -mail: newbusiness @tasconline.com Fax: 608 - 661 -9638 Mail: TASC, c/o New Business Department Internal Use Only: ❑ Large Client Qualifier 1 2302 International Lane, P.O. Box 14140, Madison, Wisconsin 53704 -3140 (1) EMPLOYER /ADMINISTRATOR Check all that apply: ® FlexSystem ❑ HSA ❑ DirectPay ❑ COBRAToday ❑ FMLAMatters ❑ PayPath ❑ ERISAEdge Contact Name Dallas Larson Title Administrator Company Name City of Centerville E-mail (Required) dlarson @centervillemn.com Company Physical Address (not PO Box) 1880 Main St. City Centerville State MN Zip 55038 Mailing Address —if different from Physical address City State Zip Phone Number (651) 429 -3232 Fax Number (651) 429 -8629 Business Federal ID # 41-1267014 NAICS or SIC Code 9199 Tax Filing Status: ❑ C -Corp ❑ S -Corp ❑ Partnership ❑ Sole Proprietor ❑ Non - Profit ❑ LLC g Other Government Nature of Business City Government Do you own an interest in any other business? ❑ Yes ® No If you are a current client of TASC, please provide your 12 -Digit TASC ID# 4301 - 8353 -4013, BR95 Current TASC service: ❑ FlexSystem ❑ HSA ❑ DirectPay g COBRAToday ❑ FMLAMatters ❑ PayPath ❑ ERISAEdge Name of Health Insurance Carrier Health Partners Carrier Group ID# Renewal Date Name of Carrier Account Manager /Rep AM /Rep Email (2) PAYMENT /BILLING INFORMATION The Enrollment Fee is due at the time of application. (South Dakota residents add 4% sales tax.) Service Initial Set -up Minimum Per Participant Annual Renewal Fee Other Fees I Fee Monthly Fee Fee (For groups with 1 -500 employees this fee will default to a minimum of $100 unless noted otherwise.) Flexsystem J $ 275 ( $ 30 $ 5 $ 50 TASC HSA (Full Service) $ i $ $ $ HSA (Limited or Plan Only) 4 ___ _._._. I $ DirectPay V $ __ _ �_ ( $ _ $ Benefits Card $ COBRAToday $ — $ E $ $ TQB $ # of TQBs H ers ' $ $ $ $ Active Assumption $ _ Eligibility Determination $ e $ $ S $ $150 /hr nnual fee, Late 5500 Filing $ s are application) HCR Notices $ 105(h) Test $ $ $ $ $ TOTAL $ ❑ Check here if you want TASC to ACH your initial set -up fees. (Fill in E - Pay information.) g Check # (Make check payable to TASC) ❑ MasterCard ❑ Visa ❑ American Express ❑ Discover Signature Name of Cardholder (Name on Card) Card # Exp. Date TC- 3923 - 080111 Employer Initial , I�TASC 15 (3) E-PAY Frequency of Invoicing: ❑ Quarterly ❑ Annually ® 1 -15 Employees (default to Annually) ❑ Send Administration Fee Invoice to different address. Billing Contact Title Address City State Zip Telephone Number E -mail (Required) E -Pay is TASC's standard method for submission of administration fees. With E -Pay, TASC conveniently deducts your fees from your checking account. Simply complete the following, signing where indicated. All written debit authorizations must agree that the Payer may revoke the authorization only by first notifying the Originator in the manner specified in the authorization. The language in the authorization represents the disclosure requirement associated with the clarification of OFAC economic sanction policies upon ACH Network Participants. Financial Institution Name State - 1 _ i_ 1 I _ _ � _ I Bank Routing Number Checking Account Number To determine your routing number, refer to your check. The routing number is always nine digits long and it is enclosed by colons. While the location of the routing and account numbers on your check varies depending on your bank, it is often printed in the bottom left corner. (4) AUTHORIZATION This Group Plan Application is a binding agreement between Total Administrative Services Corporation ("TASC") and you and, if applicable, the company or other legal entity you represent (collectively, "you "). By signing this Group Plan Application, you accept the terms of the Service Level Agreement. If this Group Plan Application is for full FlexSystem, TASC RSA, DirectPay HRA, COBRAToday, FMLAMatters, ERISAEdge, and /or PayPath plan administration, you acknowledge receipt of the HIPAA business associate terms and conditions provided to you with this Group Plan Application ( "Business Associate Agreement "), and you agree to be bound by the terms and conditions, as stated therein, of the Business Associate Agreement. A copy of the Business Associate Agreement must be returned with this completed Group Plan Application. Further, you, as plan sponsor and plan administrator, and on behalf of, the plan set forth in this Group Application, hereby appoint TASC and /or its subcontractors or agents to act as an authorized agent for purposes of receiving and /or retrieving electronic reports /responses ( "Claim Feed Information ") from the insurance carrier(s) listed in this Group Application or otherwise identified by you on your behalf. TASC and /or its subcontractors or agents use and disclosure of Claim Feed Information shall be subject to the terms of the Business Associate Agreement. I have read, understand and agree to the terms and conditions stated in this Group Plan Application, the Service Level Agreement, and the Business Associate Agreement (if applicable), as attested by the signature below, effective on the date of the signature. X Employer (sign here) Title City Administrator Date 9 - 20 - 12 1 certify that the names listed below have HIPAA Business Associates Agreements with our company and are authorized to access information on our behalf. Name Allan Roth Name Dan Reynoso Name Bill Singer Provider /Agent Name A.T. Grou Provider /Agent Number 163298891 Retail Code Primary Account Representative of Provider /Agent Name Stephanie Roth E - mail Stephanie.roth @at- group.net (5) FLEXSYSTEM FlexSystem Administration Options (Check only one): g FSA ❑ SIMPLE FSA ❑ POP (only fields with *) *Total number of eligible employees 11 Specify all applicable payroll cycles (12, 24, 26, etc) 24 Number of payrolls in first year � Number of pre -tax deductions in a typical 12 month Plan Year 24 *Do you currently have a Section 125 Plan? ❑ Yes ® No If yes, indicate the following: Type of Plan: ❑ FSA ❑ POP List ERISA Plan Number Number of Participants 1 Name of Administrator If you have a current FSA, indicate who will administer the Plan's Grace and Run Out: ❑ Prior Administrator ❑ TASC Prior Plan Year New Plan Year If "Yes ", indicate number of days: Default Grace Period (Plan Extension): ❑ N/A ❑ No ❑ Yes ❑ No ❑Yes 75 days Run -Out Period: ❑ N/A ❑ No ❑ Yes ❑ No Yes 90 days NOTE: Grace and Run Out are consecutive, NOT concurrent. If you choose 75 days for the Grace and 90 days for the Run Out, your plan will extend a total of 165 days. TC- 3923 - 080111 Employer Initial , f`TASC 1 6 (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 (E) Plan Funding (Required) The funding of your Participants' Flexible Spending Accounts will be set -up according to your payroll schedule. The Expected Date of Receipt (EDR) is the date TASC will expect to receive your funding payment. You may set your EDR to be the same day as your payroll or up to three days following payroll. The default method for making the contributions is TASC Auto ACH (on the EDR on your behalf, TASC initiates submission of your funding via ACH). Select from below to initiate the fulfillment of this requirement. To start this process, (1) choose which ACH process you want, (2) select your EDR, and (3) provide your bank information. (1) TASC Auto ACH (TASC initiates TASC's funding payment via ACH on the EDR.) This is the default selection. ❑ Client initiates funding payment via MyTASC on or before the EDR. Note: Under this option, TASC will use your Account and Routing Numbers to post any unpaid funding amounts that are one (1) business day past the EDR. Note: Additional annual fee will apply if ACH is not elected ($10 per payroll). (2) Please indicate the number of business days TASC will receive your funding payment: Same Day as payroll (default) ❑ 1 Day after payroll ❑ 2 Days after payroll ❑ 3 Days after payroll (3) Bank Routing Number Checking Account Number 1 i (F) TASC Card Feature For auto - substantiation, enter all applicable co -pay amounts: ❑ Medical /Office $ ❑ Prescription Drug $ ❑ Opt Out of TASC Card (additional fees apply) FlexSystem Admin. Only - Special Instructions (6) TASC HSA (HEALTH SAVINGS ACCOUNT) TASC HSA Plan Selection: ❑ TASC HSA Full Service* ❑ HSA Limited* ❑ HSA Plan Only HSA Plan Start Date: Number of RSA Eligible Employees: Is this an existing HSA? ❑ Yes ❑ No Number of Payroll Contributions: Date of Employee's first payroll contribution: Frequency of Employee Contributions: ❑ Weekly ❑ Bi- Weekly ❑ Monthly ❑Other (please explain) Employer Contributions: ❑ Yes ❑ No Amount of Employer Contribution: $ Is the Employer Contribution set up based on individual HSA or Family HSA? ❑ Individual ❑ Family ❑ Both Is this a one time Employer Contribution? ❑ Yes ❑ No If yes, please provide date of one time contribution: If no, the Employer Contributions will be made: ❑ Annually ❑ Quarterly ❑ Monthly ❑ Each pay period *ADDITIONAL FORMS REQUIREMENT: The TASC HSA Payroll Schedule Request form for each payroll group and an HSA ACH Bank Withdrawal Authorization form, and must be submitted with all full service TASC HSA applications. ❑ I understand the pay dates can NOT be changed once the plan is enrolled. ❑ I understand TASC will send an e-mail prior to withdrawing funds for my account and that I should contact TASC with any changes no later than three days prior to the employee's payroll date. Disclaimer for a stand -alone HSA Plan (not combined with TASC FlexSystem): TASC has developed a service known as "TASC HSA" that provides full administrative services for Health Savings Accounts. It is understood that the client wishes to add the HSA to its current Section 125 Plan and that the client acknowledges they have amended their Section 125 Plan to include the required HSA language to allow HSA contributions to be pre -taxed and their Section 125 Plan Documents and SPD's are current according to Federal Law. TC -3923- 080111 Employer Initial Mk. TASC' 18 ❑ I understand the terms of a stand -alone TASC HSA Plan (sign below) Employer Signature Date TASC HSA Admin. Only - Special Instructions (7) DIRECTPAY Dire Pay Plan Selection (Check only one): [ Health Reimbursement Arrangement (HRA) ❑ Direct Reimbursement (DR) DirectP. Administration Options (Check only one): ❑ Full Administration ❑ Self Administration Number of .rticipants ERISA Plan Number Do you currently have an HRA or DR Plan? ❑ Yes ❑ No Number of full- 'me and part -time employees (needed to determine CMS Reporting Requirement): (A) Participant an. ligibility Requirements Choose one of the • Ilowing: ❑ Eligibility require ' -nts include participation in the named Health Insurance Plan. ❑ The following eligibili requirements apply (choose all that are applicable): ❑ Part -time employee orking at least hours of work per week will be included (maximum of 25 hours) ❑ Seasonal employees wo ing at least months of work within a year will be included (maximum of 7 months) ❑ Employees reaching -ars of age will be included (maximum 25 years) ❑ Current employees completing months of service with the employer will be included (maximum 36 months) ❑ New employees completing •onths of service with the employer will be included (maximum 36 months) (B) Available Benefits and Qualified Expenses Each Plan selected requires a separate DirectPay Pia • Application. Plan administration fees and funding arrangements apply to each Plan Application. Check only one Plan perApplic• 'on. Plan 1 Plan 2 Plan 3 I Plan 4 Plan 5 Plan 6 (Plan 7 0 Medical 0 Medical 0 Medical 0 Medical 0 Medical 0 Uninsured 1 0 Dental Plan Deductible Deductible & ! Deductible & Deductible, Co- Deductible, Co- Medical Only Prescription Co- Insurance pay, & Prescription pay, Co- Insurance, I Select Benefits 0 Dental Prescription I 0 Orthodontics Minimum Funding at 25% at 50% at 50% at 50% I 50% at 50% at 25% or dental -- -- - - - -._ —. 1 i premium method Funding for plans are calculated based on anticipated utilization. If you do not see your plan desi. • please call TASC Provider Services at 1.800.422.4661 to discuss plan set up. Name of Health Insurance Carrier Is your health plan a High Deductible Health Plan? ❑ Yes ❑ No If yes, please indicate the health plan deductibles: $ Individual $ Family DirectPay Deductible Amount: Individual $ Family Maximum $ ❑ by Mem. -r ❑ by Family Aggregate DirectPay /Employer Reimburses: % From $ to $ DirectPay /Employer R-' bursed $ % From $ to $ DirectPay /Employer Reim. rsed $ % From $ to $ DirectPay /Employer Reimbur- -d $ % From $ to $ DirectPay /Employer Reimburse, Maximum DirectPay /Employer reimbursement per Individual $ Maximum DirectPay /Employer reimbursement per Family $ ❑ by Member ❑ by Family Aggrega TC-3923-080111 Employer Initial 'TASC' ma, 19 ) Plan Start • Check if Mid Plan Year takeover — If elected, please indicate the current Plan Year dates under the current third party administrator. From: / / (mo /dd /yr) To: / / (mo /dd /yr) TASC 'rst year administration shall begin on the first day of / (mo /yr) and continue for consecutive months. For the -cond and successive years, the Plan shall operate starting on the first day of / (month /year) and continue for the fo 'wing successive twelve (12) month period. Note: Plans need not run on the calendar year (i.e. January 1 - December 31). Are you choos g a short Plan Year (less than 12 months)? ❑ Yes ❑ No If yes, do you wis ' to extend a deductible credit to your Participants based on the amount of the health insurance deductible that has been satis -d thus far within this Plan Year? ❑ Yes ❑ No If yes, please submit credit amounts. (D) Plan Funding (Require. or full administration Plans) To fund your account, Direct •y (TASC) will initiate debit entries from the checking account and financial institution named below: 11 l - i - -J _1_ 1 - -; Bank Routing Number Checking Account Number DirectPay Admin. Only - Special Instru ns Funding: % (Minimum of 25 %) (8) COBRATODAY Total number of employees . Total numb: of employees on employer's health insurance plan Current COBRA administrator: ❑ Self ❑ Other Current number of participants in COBRA* (A) Subsidiaries, Affiliates or Divisions Identify all subsidiaries, affiliates, or divisions to be included under thi . rogram and identify whether they are to be established as a separate group for service communications. Set -up 5 • aratelv 1. Yes ❑ ❑ 2. Yes ❑ No 3. Yes n No [7 (B) Health Carriers Identify all health carriers (including current health insurance plan, HMO, dental, vision, EA• MFSA, etc.). Please note if any Plan is self- insured: 1. 4. 2. 5. 3. 6. (C) Plan Start Applications must be received by the 15th of the month if they are to begin on the first day of the , Ilowing month. First year administration shall begin on the 1st day of month /year. (D) COBRA Period Begins: ❑ First of month, following qualifying event ❑ Day after qualifying event ❑ Other (please specify): *Premium Collection Form is required at time of Plan Application along with Takeover Qualified Beneficiary Form(s). COBRAToday Admin. Only - Special Instructions TC -3923- 080111 Employer Initial I ,'LTASC 20 (9) FMLAMATTERs (A FMLA Plan Information • mber of Employees: Number of Employees Currently on FMLA Leave (Additional Fees Apply): Nu ser of Company Locations: State Abbreviation and Corresponding Company Location Code: Eligibil '1 to be determined by TASC? ❑ Yes ❑ No (Please note that determination of eligibility by TASC may incur additional costs.) Will your LA run concurrent with your workers compensation and short-term disability plans? ❑ Yes ❑ No Will you be - nually reporting FMLA hours used or providing an hour data feed? ❑ Manual ❑ Data Feed FMLA 12 -mont Tracking Type (e.g., rolling, calendar, etc.): (B) Plan Start Date: FMLAMatters Admin. Only Special Instructions • (10) ERISAEDGE (A) Plan Design The following benefits are subject to ERISA. Plea - complete each column as it relates to all benefits offered by the Employer. Column A: List of applicable health & welfare benefit- ubject to ERISA - Indicate by completing all columns B -1 for benefits offered by Employer. Column B: Contract Year - For each applicable benefit off- ed, enter the ACTUAL Contract Year of the policy with each carrier. Example: Health- Contract Year is January 1- renews each Ja ary 1. Column C: Benefits Covered Under Group Insurance (Y /N) - en -r Yes if covered under Group Insurance Policy - N if not. Column D: Pre -Tax Benefit Y/N - For all applicable Employer bene s offered; are the employees allowed to pre -tax their contributions under your Section 125 Plan, Y /N. Column E: Benefit Renewal Period - Typically will be same as Contract r- ewal unless the benefit renews, other than on the Contract Policy Year with carrier. Example: For Health- Contract Year with carrier is March 1- Febru • 28 but the benefit is a Calendar year deductible year. In this example, for health in Column 8 the Contract Year will be March 1 and Column E will be Ja • uary 1. (A) (B) (C) (D) _.. (E) ( (G) (H) (I) Contract Benefits Pre -Tax Benefit Carrier N. • e Employer Paid? Funding Total Number Year Covered Benefit Renewal Employee Paid? Arrangement of Participants Under Group (Y /N) Period Or Both? Sl - Self - Insured (not including Ins. (Y /N) I Fl- Fully- Insured Dependents•) EX- Experience Rated �— - � Health Dental Vision Life I i STD LTD Severance : 11:1 1 Ins. Policy Wellness or + EAP Stop Loss - -- - - -- �------ ----- - - - --- Insurance Voluntary I { - - - -- -- - --- - - - -- - Products TC -3923- 080111 Employer Initial ' '`TASC 21 :) Plan Start Date: * Re• ires Certificate of Coverage, which can be obtain from each carrier, must be received within two weeks of application submittal. ERISAEd: • Admin. Only - Special Instructions (11) PAYPATH (A) Fast Track Applicati • Plan Information Number of Employees: Frequency of Payroll (Wee ly, Bi- Weekly, Monthly, etc.): Fast Track Application Proces equires a follow up "telephone application" appointment with a TASC representative who will obtain more detailed Payroll inf. mation from you and complete the application process. A representative will be contacting you shortly to setup an appointment ti ' e for this "telephone application" Preferred method of contact to schedu • "telephone application" appointment (phone or email): Best Time(s) to Contact: Owner /Principal's Guarantee Because I am an owner and /or principal of the employer iden.'fied in this Group Services Plan Application ( "Administrator ") and will benefit from TASC agreeing to provide the PayPath services .. Administrator, I agree to guarantee payment of all obligations of Administrator under the Group Services Application and Servi • - Level Agreement (together, the "Agreement "). This is an unconditional and continuing guarantee of payment of Administrator obligations. I agree that my guarantee shall not be released, in whole or in part, or discharged by: (i) the renewal, extension, mo.'fication or alteration of the Agreement; (ii) any waiver, release or termination of any right or remedy of Administrator under t - Agreement or the failure of Administrator to assert or claim any right, benefit, defense or remedy it may have under the Agre: ent; (iii) the invalidity or unenforceability of any of the payment obligations of Administrator; or (iv) the insolvency, bankruptcy, liq. idation or dissolution of Administrator. I expressly waive: (i) demand of performance or payment, presentment, protes notice of dishonor, or nonpayment of any of Administrator's obligations; (ii) notice of acceptance of this guarantee and notice of a • liability to which it may apply; (iii.) all other notices and demands of any kind; and (iv) any defenses of Administrator pertaining • its obligations except for the defense of discharge by payment. TASC shall not be required to pursue any remedies against Ad istrator as a condition to enforcement of my guarantee. Signature Date Printed Name TC -3923- 080111 Employer Initial I A.T 22 Service Level Agreement SECTION I THIS SERVICE LEVEL AGREEMENT ( "Agreement "), entered into by and between Total Administrative Services Corporation (hereinafter referred to as the "Administering Agent" or "TASC ") and the employer identified on the Group Services Plan Application attached hereto ( "Plan Application," with the employer identified therein hereinafter referred to as "Administrator" or the "Plan Sponsor "). This Agreement shall be effective on the date of the Plan Sponsor's signature on the Plan Application. The terms of this Agreement apply to the plan or plans identified on the Plan Application (the "Plan," whether one or more). Except as otherwise provided in this Agreement, the terms of this Agreement shall be in effect indefinitely and will renew automatically. Services to be Provided by the Administering Agent Under this Agreement, the Administering Agent will provide timely administration and management of the Plan identified in the Plan Application substantially as outlined in the applicable product administration manual and /or materials. Services provided by the Administering Agent are subject to change upon written notice to the Plan Sponsor. In the case of FlexSystem, DirectPay and FMLAMAtters Plans, Agent will also provide support audit assistance under the terms of the applicable Audit Guarantee. Responsibility as the Plan Sponsor /Administrator Pursuant to this Agreement, the Plan Sponsor must present to the Administering Agent, in an accurate, complete and timely manner, all relevant and requested information necessary or desired for administrative functions to be performed by the Administering Agent. This may include, but shall not be limited to enrollment and re- enrollment information, notification of employee and employer changes, payments relative to fees or funding of the Plan and its features and processes as well as information and data necessary for completing testing, reporting and filing requirements applicable to the Plan. The Administering Agent shall rely on the accuracy and timeliness of information provided to it by the Plan Sponsor. The Administering Agent has no responsibility to review or verify data provided by the Plan Sponsor; the Administering Agent is not responsible for detecting illegal acts by, and /or misrepresentations of, the Plan Sponsor's employees or representatives. Failure to meet deliverable expectations, including but not limited to those noted above and elsewhere in this agreement, in an accurate, complete and timely manner will result in a status of delinquency. Delinquency status will result in service interruptions and /or delays including, but not limited to claim processing reporting and filing which will be the liability of the Plan Sponsor. It is the Plan Sponsor's responsibility to educate and inform Plan participants on the services being provided, including the delivery of administration materials (where needed) as well as compliance documents (e.g., Summary Plan Description). The Plan Sponsor is responsible for executing and retaining the Business Associate Agreement (where applicable) provided in the administration materials. The Plan Sponsor shall have the sole and final discretionary authority in respect to all legal and administrative functions of the Plan. Financial Responsibility of the Plan Sponsor /Administrator Responsibility for payment of Plan benefits lies with the Plan Sponsor. Where applicable to the Plan, Plan funding will be processed via ACH transaction and the Plan Sponsor hereby authorizes the Administering Agent to initiate credit /debit entries to the bank account indicated in the Plan Application and further authorizes the Plan Sponsor's bank to debit the same to such account. If the Administering Agent does not receive payment for such invoices within ten (10) business days, the Plan Sponsor hereby authorizes the Administering Agent to initiate a debit entry to the bank account indicated in the Plan Application for the invoice amount. A fee will be charged for all debit entries that reject for insufficient funds or closed account. This authority is to remain in full force and effect until the Administering Agent has received written notification from the Plan Sponsor of its termination in such time and in such mariner as to afford the Administering Agent and the Plan Sponsor's bank a reasonable opportunity to act on it. It is understood that the purpose of this authorization is to provide a means of payment for the administrative services provided to the Plan Sponsor by the Administering Agent and the funding of the Plan sponsored by the Plan Sponsor. Although the Administering Agent may fund or make payment on behalf of the Plan Sponsor, ultimately all Plan contributions and liabilities are the responsibility of the Plan Sponsor, including under any circumstances where the Plan Sponsor uses a third party to make payment for Plan benefits. The Administering Agent reserves the right to correct any processing errors, making a reasonable effort to recover any payment made in error for any reason and the Plan Sponsor authorizes the Administering Agent to debit or credit the Plan Sponsor's account as necessary to correct such errors. The Administering Agent will not be liable for any payments made in error. The Administering Agent will invoice or make adjustments to the Plan or the Plan Sponsor as deemed necessary. The Plan Sponsor understands and agrees Plan Sponsor shall be liable for and hold the Administering Agent harmless from any and all fees or penalties assessed by the Internal Revenue Service, the Department of Labor or any other federal, state and /or local government agency arising from the Plan; except in the case of of FlexSystem, DirectPay and FMLAMAtters Plans, as otherwise outlined in the Audit Guarantee, or in the case of a PayPath Plan, as otherwise set forth in Section II of this Agreement. Any request for refunds or adjustments by Plan Sponsor will be processed only after verification is made that sufficient funds were received by Administering Agent from the Plan Sponsor's bank account to cover all payments made by, and fees and other amounts due to, the Administering Agent. No refunds or adjustments will be made while the Plan Sponsor is in default under this Agreement. Representations and Warranties of Plan Sponsor /Administrator The Plan Sponsor represents and warrants that: a. All information about the Plan Sponsor provided by the Plan Sponsor to the Administering Agent is and will be correct, including, as applicable, the Plan Sponsor's correct legal name, tax identification numbers, filing frequency requirements, and tax rates. TASC shall have no responsibility for errors or omissions related to erroneous information from the Plan Sponsor of the Plan Sponsor's failure to provide information; and b. The Plan Sponsor is duly organized, validly existing, and fully authorized to enter into this Agreement. The individual executing the Plan Application on behalf of the Plan Sponsor is fully authorized to do so. Terms of Payment The Plan Sponsor agrees to pay the Administering Agent for services provided under this Agreement in accordance with the fees determined on the Plan Application. Payment for services will occur via E -pay or invoices will generate prior to the applicable service period and are due according to the terms on the invoice. In addition to the fees determined on the Plan Application, all interest on Plan funds shall be retained by TASC as a supplemental fee and such fees shall be considered earned at such time as any interest accrues on the Plan funds. Where applicable, funds attributed to Plan participant reimbursement checks not presented for payment within ninety (90) days of the end of the Plan year shall be retained by the Administering Agent as a supplemental fee used to defray administrative costs, The Administering Agent will adjust administrative fees on an annual basis. The adjustment will equal the average change in the consumer price index (according to the Bureau of Labor Statistics) over the prior three (3) year period. The Administering Agent may further adjust on a triennial basis (once every 3 years) by an amount relative to the current prevailing market rate for the same or similar services. The forgoing notwithstanding, the Administering Agent may adjust fees at its discretion at anytime, by any amount and for any reason. Any Plan funding ACH debits that are rejected or which, for any reason, are not processed through the Plan Sponsor's bank will result in the Plan being placed in delinquency status until such ACH debit is properly processed or otherwise resolved. Default The Administering Agent's obligations are subject to the Plan Sponsor's timely performance of its obligations and responsibilities. The Administering Agent will not be responsible for damages due to any events of default by the Plan Sponsor. In the event of a default by the Plan Sponsor in the payment of fees or Plan benefits, or any other term, covenant or condition of this Agreement, the Plan Sponsor may be assessed additional fees or this Agreement may be terminated and all amounts due and to become due to the Administering Agent shall become immediately due and payable, at the Administering Agent's sole option. In the event of a default by the Plan Sponsor, the Administering Agent reserves the right to suspend all or any services to the Plan Sponsor and the Plan, including the reporting or processing of Plan data and payments, and the Administering Agent will not be responsible for the timeliness or accuracy of any reporting, participant payments, tax deposits or payroll payments until the default(s) has been cured and all outstanding obligations the Plan Sponsor have been paid to the Administering Agent. The Plan Sponsor agrees to defend, indemnify and hold the Administering TC- 3923 - 080111 Employer Initial , I ` TASC 23 Agent harmless from any claim, liability, damage or expense, including reasonable attorneys' fees, which the Administering Agent incurs as a result of the Plan Sponsor's default under this Agreement and /or the Administering Agent's exercise of its rights under this Agreement. Events of default by the Plan Sponsor shall include: a. Providing the Administering Agent with incorrect or incomplete information; b. Failing to timely provide data, other information, or notices required under this Agreement; and /or c. Failure to timely pay fees, remit Plan funds, or pay other amounts owed the Administering Agent. Termination of Agreement Except as otherwise provided in this subsection, this Agreement shall continue in effect until it is terminated by the Plan Sponsor or the Administering Agent with a minimum of sixty (60) days written notice prior to the Plan renewal date. The Plan Sponsor shall pay any termination fees specified in the Plan Application which shall be due at the time of any notice of non - renewal or termination. If services are terminated by the Plan Sponsor prior to the end of the existing Plan year or other applicable service period, the Plan Sponsor shall be responsible for administration fees for the remainder of that Plan year or other applicable service period. Failure to provide timely written notice of termination will result in an additional fee due by the Plan Sponsor equal to fees assessed to the Plan Sponsor during the sixty (60) days preceding the termination. If services are terminated under this Agreement, the Plan Sponsor will be responsible for providing any outstanding services required under the Plan. This Agreement may be terminated by the Administering Agent by providing the Plan Sponsor with a ten (10) day written notice of said termination if this Agreement is being terminated for the Plan Sponsor's failure to pay fees, remit Plan funds, or any other default under this Agreement by the Plan Sponsor. Either party may terminate this Agreement and regard the other party as in default by giving the other party written notice of the termination, if the other party becomes insolvent, makes a general assignment for the benefit of creditors, suffers or permits the appointment of a receiver for its business or assets, becomes subject to any proceedings under any bankruptcy or insolvency law (which has not been terminated within thirty (30) days of any filing) whether domestic or foreign, or has been wound up or liquidated, voluntarily or otherwise. Upon and after the expiration or termination of this Agreement, the rights granted to the Plan Sponsor pursuant to this Agreement shall revert back to the Administering Agent. In addition, it is understood that termination of this Agreement also terminates the provision of the prototype Plan Document (where applicable) and the Plan will thereafter be perceived as individually designed and the sole responsibility of the Plan Sponsor. Within twenty (20) days after termination or expiration of this Agreement, the Plan Sponsor shall return to the Administering Agent all manuals, brochures, customer and vendor data bases, any other documents regarding the TASC programs and systems and any copies thereof. In addition, the Plan Sponsor shall refrain from any further direct or indirect use of or reference to the TASC marks, systems, publications, manuals, brochures, documents and computer databases in connection with the marketing, use, implementation, license, sale or distribution of any program, system or Plan offered by the Administering Agent. Finally, the termination of this Agreement shall not affect the duty of the Plan Sponsor not to infringe on the Administering Agent's trademarks and copyrights and not to disclose and keep confidential all said confidential information supplied to the Plan Sponsor by the Administering Agent. Limitations of Warranties and Liabilities Except as expressly set forth in this Agreement, the Administering Agent disclaims any and all express warranties, warranties of fitness for a particular purpose and implied warranties of merchantability. Administering Agent will not be liable for any loss of business or profits, or for any consequential, incidental, punitive, or similar damages, or, other than as set forth in this Agreement, for claims of damages made by any third party for any cause whatsoever, regardless of the form of action, whether in contract or in tort, including negligence, even if it has been advised of the possibility of such damages. In no event will the Administering Agent's liability exceed the payments made by Plan Sponsor to the Administering Agent within the previous six (6) months for FlexSystem, DirectPay, COBRAToday, or FMLAMatters services provided under this Agreement or within the previous payroll period for PayPath services provided under this Agreement, and such amount shall be reduced by the total amount due from the Plan Sponsor to the Administering Agent under the terms of this Agreement. This shall be the Plan Sponsor's exclusive remedy. No action, regardless of form, arising out of the services provided under this Agreement, may be brought by the Plan Sponsor more than two years after the date the last services are provided under this Agreement. Each party acknowledges that this limitation of liability reflects an informed, voluntary allocation between the parties of the risks (known and unknown) that may exist in connection with this Agreement. Money Back Guarantee If you are not entirely pleased with the Plan, simply return all Plan materials within 30 days of the date received to obtain a refund of the related fee, less the $100 nonrefundable minimum fee. SECTION it In addition to the preceding paragraphs of Section I, the following terms and conditions shall be applicable depending on the Plan elected by the Plan Sponsor. Flexsystem All claims submitted to FlexSystem other than substantiated copayments, recurring medical expenses or debit card charges substantiated in real time, through an inventory information approval system, or through other means compliant with Internal Revenue Service regulations, must be substantiated by independent third -party information prior to claim payment. If, at any point, the Plan Sponsor makes the decision to adjudicate Plan participant claims, all claims and substantiation submitted to the Administering Agent by Plan participants shall be forwarded to the Plan Sponsor for review prior to payment of the claim by the Administering Agent. If Plan Sponsor does not reject the claim within three (3) business days of receiving the forwarded claim, the Administering Agent shall pay the claim. Regardless of whether Plan Sponsor and /or Agent is adjudicating claims, any and all unsubstantiated or fraudulent claims by Plan participants (regardless of whether by use of the debit card, web submitted, Agent or Participant submitted or manually submitted claims) and amounts distributed to a Plan participant that exceed the Participant's account balances are the Plan Sponsor's responsibility. Agent reserves the right to request a deposit or payment if the aggregate Participant account balance is, or is likely to be, less than $0 at any point. The Agent will require a deposit or payment for negative Plan participant account balances or potential negative Plan participant account balances upon termination of the Plan. Plan fees are calculated at a minimum or per Plan participant fee which ever is greater. Fees are also calculated on the number of Plan participants in the Plan, including terminated employees, at the time of invoice. The Plan Sponsor is responsible for administration fees for the entire Plan year, including grace period and run out period. Failure to remit Plan participant funds or payment for administrative services will result in a disruption of services, the forwarding to collections and /or termination of the Plan. TASC HSA Agent provides administrative services to assist Plan Sponsor in offering its eligible employees the option to open Health Saving Accounts (HSA). Plan Sponsor acknowledges that Agent is not qualified to act as a trustee or custodian of the HSA funds and is not acting as such. Agent provides the Health Savings Account (HSA) services pursuant to an agreement with one or more third party financial institutions that serve as custodian and trustee of the HSA funds ( "Custodian "). Agent is not responsible for claims, damages or liabilities arising from failure of Custodian to perform its obligations or provide resources as required by its agreement with Agent (Custodian is, however, liable for failure to perform its obligations) Plan Sponsor represents and warrants that, to the best of its knowledge, the group health plan sponsored and maintained by Plan Sponsor pursuant to which medical coverage is provided to its employees electing to open a HSA with Custodian will be, at all times relevant to this Agreement, an HDHP, in accordance with Section 223 of the Internal Revenue Code of 1986, as amended (the "Code "). Plan Sponsor acknowledges and agrees that the HSAs owned by its employees and held by Custodian shall not be employee benefit plans and the assets held in the HSA shall not be plan assets subject to the provisions of the Employee Retirement Income Security Act of 1974 ( "ERISA "). Plan Sponsor acknowledges and agrees that at all times relevant to this Agreement participation in HSAs by employees shall be completely voluntary; and Plan Sponsor shall not: (i) limit the ability of participants to move monies in their HSAs to another HSA (except to the extent of restrictions imposed by the Code; (ii) impose any conditions on the utilization of HSA monies beyond those permitted by the Code; (iii) represent or advise that the HSAs are an employee welfare benefit plan established or maintained by the employer; or (iv) receive any payment or compensation in connection TC-3923-080111 Employer Initial TASC 24 with an HSA. Plan Sponsor acknowledges that Agent may, from time to time, change the Custodian and may subcontract other aspects of its performance. Agent may not, however, require any participant to close an HSA with the then current Custodian. Agent shall have no responsibility with respect to contributions paid by Plan Sponsor, participants or other contributor or transferor to the HSAs, other than to allocate the contributions in accordance with clear instructions received from Plan Sponsor, participants, or other contributor or transferor. Agent shall have no obligation to take affirmative actions to collect monies paid as contributions, such as, by way of example, to pursue a check or electronic payment transfer from Plan Sponsor or a participant or other contributor or transferor that does not clear. If this Agreement is terminated mid plan year, Plan Sponsor shall continue to be responsible for payment of administration fees set forth in the Group Plan Application for the entire plan year. Administration fees shall be calculated on a minimum or per participant basis, whichever is greater. For purposes of calculating fees on a per participant basis, the number of participant shall be determined as of the invoice date and shall include any employees terminated mid year. In addition to the administration fees set forth in the Group Plan Application, Agent shall also be entitled to payment from the Plan Sponsor of all expenses and costs reasonably incurred by it in the administration of the HSAs, including, but not limited to, reimbursement for the cost of debit card transactions, including any fraudulent charges, unless such expenses and costs are paid directly by participants. DirectPay Fraudulent claims by Plan participants (regardless of whether by use of the debit card, web submitted, TASC submitted, medical provider or manually submitted) and amounts distributed to Plan participants that exceed the Plan participants' account balances are the Plan Sponsor's responsibility. The Administering Agent also reserves the right to request a deposit or payment when the fund account goes into a negative account balance. Fees are calculated at the minimum administration fee or health enrolled fee which ever is greater. Fees are also calculated on the number of health enrolled in the Plan, including terminated employees at the time of invoice. The Plan Sponsor is responsible for administration fees for the entire Plan year, including the run out period. Standard run out period is 90 days following the end of the Plan Year. COBRAToday The Administering Agent will forward onto the Plan Sponsor the COBRA continuee premium amounts. COBRAToday charges the COBRA continuee an additional two percent above the premium amount for handling the payments. This two percent is maintained by COBRAToday. If the COBRA continuee's premium check is rejected due to non - sufficient funds, the Plan Sponsor will be responsible for reimbursing the Administering Agent any distributed amounts for the continuee while the Administering Agent attempts to collect dollars from the COBRA continuee. FMLAMatters The Plan Sponsor agrees, as is necessary for the Administering Agent to complete its responsibilities herein, to provide the Administering Agent with the following information. The Plan Sponsor understands they are responsible for notifying the Administering Agent when certain qualifying events occur, and that the Administering Agent cannot carry out its responsibilities without notification as defined, with relations to the Plan Sponsor's employees. 1) Absences, or proposed absences, in excess of 3 days from regularly scheduled work for the circumstance(s) of a birth, adoption or placement in foster care of a child, the care of a seriously ill child, spouse or parent, or the employee's own illness, 2) Eligibility of the proposed employee; employment by the Plan Sponsor in excess of 12 months and cumulative work hours of 1,250 in the preceding 12 months, 3) Notification to the Administering Agent if an employee who has been out on leave has returned to work. The Plan Sponsor must provide to the Administering Agent and keep the Administering Agent currently informed, of all pertinent information relating to the Plan Sponsor at the inception of the contract and as may be later modified by the Plan Sponsor, including but not limited to: 1) Advise the Administering Agent of any changes in employee population per location that may affect FMLA administration (increase or decrease with relation to the minimum of 50 employees per covered location), 2) Advise the Administering Agent of any newly acquired locations, in order to ensure compliance with FMLA administration, 3) Advise the Administering Agent of any divested location (closing or sale to separate organization) that affects FMLA administration, 4) Provide Administering Agent with current information regarding all benefit programs; providers rates and other pertinent information. PayPath 1. TASC'S RESPONSIBILITIES: a. Tax filings. TASC will serve as a limited agent for Administrator only for purposes of any required deposits and filings with the Internal Revenue Service and /or any state reporting agency. TASC is not otherwise an agent of Administrator, nor is TASC in partnership or otherwise affiliated with Administrator's business. Any requests to deviate from the current withholding tax tables must be made in writing and will be the responsibility of the Administrator. TASC will not be responsible for tax deposits or tax reporting for payrolls that were not processed by TASC. b. Penalties and other assessments. Notwithstanding anything to the contrary in Section I of this Agreement, if TASC makes an error or omission that results in an assessment by a taxing authority against Administrator that includes penalties and /or Interest, then TASC's sole liability will be to pay the penalties and /or interest. It remains Administrator's responsibility to pay any uncollected tax due. TASC will not be responsible for penalties, interest or other damages or liabilities otherwise assessed against Administrator, including due to: i) tax deposits or other amounts that are returned for insufficient funds ( "NSF ") from Administrator account, a closed Administrator account, or any other reason beyond TASC's reasonable control; or ii) Administrator's submission of untimely, inaccurate or illegible information to TASC. Administrator agrees to hold TASC harmless from any and all such penalties and interest (other than as described in the first sentence of this subsection 1.d.), and other damages and liabilities, which will be Administrator's sole responsibility. 2. ADMINISTRATOR'S RESPONSIBILITIES: Administrator agrees to accept the following obligations and responsibilities with respect to the Plan and PayPath services: a. Administrator will submit to TASC Administrator's payroll data no less than three (3) business days in advance of the date payroll is to be effective. Once payroll data is submitted, Administrator cannot change the data. Administrator will make sufficient funds for direct deposit available to TASC in escrow no less than two (2) business days in advance of the date payroll is to be effective. Failure to timely submit payroll data and /or funds may result in delay of payment to employees, additional charges, or in Administrator default. b. Administrator will notify TASC in writing within fifteen (15) business days of any voided checks, overpayments, underpayments, or other payroll errors. If timely notice is not provided to TASC, additional charges may apply to correct these errors. TASC will not be responsible for uncollectible overpayments to employees, unless such overpayments are due solely to TASC's negligence. c. Administrator will notify TASC in writing no later than fifteen (15) days prior to any changes to Administrator's: (1) bank accounts that will affect the Plan or provision of PayPath services, including but not limited to payroll, reporting, fee collection, or tax deposits; (2) filing frequency; or (3) tax rate or tax jurisdiction. Administrator will notify TASC promptly if Administrator expects to employ, or has employed, persons in tax jurisdictions not presently included in the Plan. TASC will not be responsible for late or incorrect tax deposits due to Administrator's failure to provide TASC with timely notifications. d. Administrator will make TASC aware of any local tax or state unemployment insurance requirements. TASC will not be responsible for ascertaining the Administrators' responsibility for local taxes or state unemployment insurance. It also shall be Administrator's responsibility to determine whether an individual constitutes an employee or independent contractor for tax and unemployment insurance purposes. Administrator will be responsible for forwarding any W -4 forms that require forwarding to IRS or any state agency. TC- 3923 - 080111 Employer Initial I , f` TASC 25 e. Administrator will forward any notice of penalty or interest assessed against Administrator to TASC within five (5) business days of Administrator's receipt of such notice. TASC agrees to acknowledge receipt of these notices in writing within five (5) business days of receipt by TASC. TASC will not be responsible for assessments that are no longer appealable, nor will TASC be responsible for interest charges that have accrued because Administrator did not timely forward a notice to TASC. f. Administrator will arrange for valuation of non -cash fringe benefits or the tax valuation of health or life insurance benefits paid to employees, partners, or corporate officers during the course of the year ( "Benefit Valuation "). TASC is not responsible for Benefit Valuation. g. Administrator will allow TASC to collect its fees for services provided as set forth on the Plan Application or a separate statement of fees and all other amounts due TASC (including any termination or NSF fees) via ACH debit. h. Administrator will be responsible for the payment of all fees and funding costs incurred by TASC to run a payroll process in the event that TASC attempts to process a scheduled payroll and the Administrator's business account does not have sufficient funds available to be pulled to fund the payroll process. i. Administrator will keep TASC informed in writing of Administrator personnel authorized to access TASC's payroll and service systems. j. Administrator agrees to obtain, prior to an employee being covered by the PayPath Plan services, written authorization from the employee for TASC to make deposits and correcting entries /debits to the employee's bank account. In the event of an overpayment to any employee that TASC cannot recover through such a correcting entry, the amount of the overpayment will be due and owing by Administrator to TASC upon notice from TASC. 3. ADDITIONAL REMEDIES OF TASC: In addition to any to remedies TASC may have at law or under Section I of this Agreement, if Administrator fails to timely pay fees and /or other amounts due TASC under this Agreement, or if Administrator has items returned for insufficient funds, Administrator shall pay such amounts immediately upon demand by TASC, plus interest at the lesser of 18% annually or the maximum rate allowed by law, plus attorneys' fees and other costs of collecting the amounts owed as allowed by law. In addition to the forgoing, and without notice to Administrator: (i) if TASC is holding Administrator money other than for tax payments, TASC may apply it to any amount Administrator owes TASC; and /or (ii) TASC may take any steps necessary to recover tax deposits made by TASC on behalf of Administrator from any taxing agencies, including, but not limited to, instructing taxing agencies to remove such deposit from Administrator's tax account(s) and credit such deposit to TASC's own tax account(s). TASC may also make appropriate reports to credit reporting agencies, financial institutions, taxing agencies and law enforcement authorities, and cooperate with such agencies, institutions, or authorities in any resulting investigation or prosecution. SECTION III The following terms and conditions shall apply to all Plans. Execution and Delivery The Plan Application is incorporated herein by reference and may be executed and delivered (including by facsimile or Portable Document Format (PDF) transmission) in one or more counterparts, all of which will be considered one and the same agreement, and this Agreement will become effective when the Plan Application is signed by a representative of the Plan Sponsor. Any such facsimile or PDF documents and signatures shall have the same force and effect as manually- signed originals and shall be binding on the Plan Sponsor /Administrator and the Administering Agent. Governing Law This Agreement shall be construed, governed by, and enforced in accordance with the internal laws of the State of Wisconsin, without giving effect to the principles of comity or conflicts of laws thereof. Entire Agreement This Agreement represents the entire agreement of the parties and supersedes any prior written or oral agreements. This Agreement shall not be altered or amended, except by written agreement of duly authorized representatives of the Administering Agent and the Plan Sponsor. Attorneys' Fees In any action at law or in equity to enforce any of the provisions or rights under this Agreement, the non - prevailing party in such litigation, as determined by the court in a final judgment or decree, shall pay to the prevailing party or parties all costs, expenses and reasonable attorneys' and accountants' fees incurred therein by such party or parties (including without limitation such costs, expenses and fees on any appeals), and if such prevailing party shall recover judgment in any such action or proceeding, such costs, expenses and fees shall be included as part of such judgment. Notices Any notice, demand or other communication required or permitted to be given to either party to this Agreement shall be in writing and shall be either personally delivered by hand or delivered by prepaid courier or sent by electronic means such as facsimile, telex or electronic mail. Any notice personally delivered or delivered by courier shall be deemed received upon delivery. Any notice sent by electronic means shall be deemed received upon the date the sending terminal confirms that the notice was received. The address to which communications shall be sent to the Plan Sponsor is identified in Section 1 of the Plan Application. Either party may change its address by giving written notice to the other party as provided in this subsection. Assignment Neither this Agreement nor the Plan Sponsor's rights or obligations may be assigned, delegated or transferred without the prior written consent of the Administering Agent. The Administering Agent may assign this Agreement without limitation. Waiver The failure of either party at any time to require performance or observance by the other party of any term or condition of this Agreement shall not affect the full right to require such performance or observance at any subsequent time. Further, no single or partial waiver of any right, power or privilege will preclude any other or further exercise of any other right, power or privilege. Severability If any term or condition of this Agreement is held to be invalid or unenforceable by reason of any statute, rule of law or public policy, all other terms and conditions of this Agreement shall nevertheless remain in full force and effect as if this Agreement had been executed with the invalid or unenforceable portion thereof eliminated. I TC- 3923 - 080111 Employer Initial f SA 26 TAs c TM BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement ( "Agreement ") is made this day of , in the year 20 12 by and between City of Centerville as plan sponsor and plan administrator acting on behalf of City of Centerville ("Covered Entity ") and Total Administrative Employer Plon Services Corporation, a Wisconsin corporation ( "Business Associate "). RECITALS WHEREAS, Covered Entity is a group health plan ( "Plan ") and wishes to engage the services of Business Associate with respect to certain administrative aspects of the Plan as more specifically set forth in a Service Level Agreement ( "SLA "); WHEREAS, Covered Entity wishes to disclose certain information to Business Associate pursuant to the terms of the SLA, some of which may constitute Protected Health Information ( "PHI ") (defined below). WHEREAS, Covered Entity and Business Associate intend to protect the privacy and provide for the security of PHI disclosed to Business Associate pursuant to the SLA in compliance with the Health Insurance Portability and Accountability Act of 1996, Public Law 104 -191 ( "HIPAA "), the Health Information Technology for Economic and Clinical Health Act, Public Law 111 -005 (the "HITECH Act "), and regulations promulgated thereunder by the U.S. Department of Health and Human Services (the "HIPAA Regulations ") and other applicable laws. WHEREAS, as part of the HIPAA Regulations, the Privacy Rule and the Security Rule (defined below) require Covered Entity to enter into a contract containing specific requirements with Business Associate prior to the disclosure of PHI, as set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504(e) of the Code of Federal Regulations ( "C.F.R. ") and contained in this Agreement. NOW THEREFORE, in consideration of the mutual promises below and the exchange of information pursuant to this Agreement, the parties agree as follows: The general terms and conditions attached hereto are incorporated herein and deemed part of this Agreement. IN WITNESS WHEREOF, the parties hereto have duly executed this Agreement as of the date first written above. COVERED ENTITY: BUSINESS ASSOCIATE: City of Centerville TOTAL ADMINISTRATIVE SERVICES CORPORATION SS/ #16."-N By: By: Print Name: Dallas Larson Print Name: Brad Hoffman Title: Administrator Title: Executive Vice President, Customer Service TC-3923-080111 Employer Initial , `TASC' 27 TERMS AND CONDITIONS 1. Definitions a. Breach shall have the meaning given to such term under the HITECH Act [42 U.S.C. Section 17921]. b. Business Associate shall mean Total Administrative Services Corporation. c. Covered Entity shall mean the party identified above. d. Data Aggregation shall have the meaning given to such term under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.501. e. Designated Record Set shall have the meaning given to such term under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.501. f. Electronic Protected Health Information means Protected Health Information that is maintained in or transmitted by electronic media. g. Electronic Health Record shall have the meaning given to such term in the HITECH Act, including, but not limited to, 42 U.S.C. Section 17921. h. Health Care Operations shall have the meaning given to such term under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.501. Privacy Rule shall mean the HIPAA Regulation that is codified at 45 C.F.R. Parts 160 and 164, Subparts A and E. j. Protected Health Information or PHI means any information, whether oral or recorded in any form or medium: (i) that relates to the past, present or future physical or mental condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual; and (ii) that identifies the individual or with respect to which there is a reasonable basis to believe the information can be used to identify the individual, and shall have the meaning given to such term under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.501. Protected Health Information includes Electronic Protected Health Information [45 C.F.R. Sections 160.103, 164.501]. k. Protected Information shall mean PHI provided by Covered Entity to Business Associate or created or received by Business Associate on Covered Entity's behalf. Security Rule shall mean the HIPAA Regulation that is codified at 45 C.F.R. Parts 160 and 164, Subparts A and C. m. Unsecured PHI shall have the meaning given to such term under the HITECH Act and any guidance issued pursuant to such Act including, but not limited to, 42 U.S.C. Section 17932(h). 2. Obligations of Business Associate a. Permitted Uses. Business Associate shall not use Protected Information except for the purpose of performing Business Associate's obligations under the SLA and as permitted under the SLA and this Agreement. Further, Business Associate shall not use Protected Information in any manner that would constitute a violation of the Privacy Rule or the HITECH Act if so used by Covered Entity. However, Business Associate may use Protected Information (i) for the proper management and administration of Business Associate; (ii) to carry out the legal responsibilities of Business Associate; or (iii) for Data Aggregation purposes for the Health Care Operations of Covered Entity [45 C.F.R. Sections 164.504(e)(2)(i), 164.504(e)(2)(ii)(A) and 164.504(e)(4)(i)]. b. Permitted Disclosures. Business Associate shall not disclose Protected Information except for the purpose of performing Business Associate's obligations under the SLA and as permitted under the SLA and this Agreement. Business Associate shall not disclose Protected Information in any manner that would constitute a violation of the Privacy Rule or the HITECH Act if so disclosed by Covered Entity. However, Business Associate may disclose Protected Information (i) for the proper management and administration of Business Associate; (ii) to carry out the legal responsibilities of Business Associate; (iii) as required by law; or (iv) for Data Aggregation purposes for the Health Care Operations of Covered Entity. If Business Associate discloses Protected Information to a third party, Business Associate must obtain, prior to making any such disclosure, (i) reasonable assurances from such third party that such Protected Information will be held confidential as provided pursuant to this Agreement and only disclosed as required by law or for the purposes for which it was disclosed to such third party, and (ii) an agreement from such third party to immediately notify Business Associate of any breaches of confidentiality of the Protected Information, to the extent it has obtained knowledge of such breach [42 U.S.C. Section 17932; 45 C.F.R. Sections 164.504(e)(2)(i), 164.504(e)(2)(i)(B), 164.504(e)(2)(ii)(A) and 164.504(e)(4)(ii)]. c. Prohibited Uses and Disclosures. Business Associate shall not use or disclose Protected Information for fundraising or marketing purposes. Business Associate shall not disclose Protected Information to a health plan for payment or health care operation purposes if the patient has requested this special restriction, and has paid out of pocket in full for the health care item or service to which the PHI solely relates [42 U.S.C. Section 17935(a)]. Business Associate shall not directly or indirectly receive remuneration in exchange for Protected Information, except with the prior written consent of Covered Entity and as permitted by the HITECH Act, 42 U.S.C. Section 17935(d)(2); however, this prohibition shall not affect payment by Covered Entity to Business Associate for services provided pursuant to the SLA. d. Appropriate Safeguards. Business Associate shall implement appropriate safeguards as are necessary to prevent the use or disclosure of Protected Information otherwise than as permitted by the SLA or this Agreement, including, but not limited to, administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of the Protected Information, in accordance with 45 C.F.R. Sections 164.308, 164.310, and 164.312. [45 C.F.R. Section 164.504(e)(2)(ii)(B); 45 C.F.R. Section 164.308(b)]. Business Associate shall comply with the policies and procedures and documentation requirements of the HIPAA Security Rule, including, but not limited to, 45 C.F.R. Section 164.316 [42 U.S.C. Section 17931]. e. Reporting of Improper Access, Use or Disclosure. Business Associate shall report to Covered Entity any access, use or disclosure of Protected Information not permitted by the SLA and this Agreement, and any Breach of Unsecured PHI of which it becomes aware without unreasonable delay and in no case later than 60 calendar days after discovery [42 U.S.C. Section 17921; 45 C.F.R. Section 164.504(e)(2)(ii)(C); 45 C.F.R. Section 164.308(b)]. f. Business Associate's Agents. Business Associate shall ensure that any agents, including subcontractors, to whom it provides Protected Information, agree to the same restrictions and conditions that apply to Business Associate with respect to such PHI and implement the safeguards required by subparagraph d above with respect to Electronic PHI [45 C.F.R. Section 164.504(e)(2)(ii)(D); 45 C.F.R. Section 164.308(b)]. g. Access to Protected Information. Within thirty (30) days of receiving a written request from Covered Entity, Business Associate shall make Protected Information maintained by Business Associates or its agents or subcontractors in Designated Record Sets available to Covered Entity, in reasonable time and manner, for inspection and copying to enable Covered Entity to fulfill its obligations under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.524 [45 C.F.R. Section 164.504(e)(2)(ii)(E)]. If Business Associate maintains an Electronic Health Record, Business Associate shall provide such information in electronic format to enable Covered Entity to fulfill its obligations under the HITECH Act, including, but not limited to, 42 U.S.C. Section 17935(e). Tc- 3923 - 080111 Employer Initial II 28 h. Amendment of PHI. Business Associate or its agents or subcontractors shall, in a reasonable time and manner, make Protected Information available to Covered Entity for amendment and incorporate any such amendment to enable Covered Entity to fulfill its obligations under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.526. If any individual requests an amendment of Protected Information directly from Business Associate or its agents or subcontractors, Business Associate shall notify Covered Entity of the request. Any approval or denial of an amendment of Protected Information maintained by Business Associate or its agents or subcontractors shall be the responsibility of Covered Entity [45 C.F.R. Section 164.504(e)(2)(ii)(F)]. Accounting Rights. Business Associate and its agents or subcontractors shall, in a reasonable time and manner, make available to Covered Entity the information required to provide an accounting of disclosures to enable Covered Entity to fulfill its obligations under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.528, and the HITECH Act, including but not limited to, 42 U.S.C. Section 17935(c). In the event that the request for an accounting is delivered directly to Business Associate or its agents or subcontractors, Business Associate shall forward it to Covered Entity. It shall be Covered Entity's responsibility to prepare and deliver any such accounting requested. Business Associate shall not disclose any Protected Information except as set forth in Sections 2.b. of this Agreement [45 C.F.R. Sections 164.504(e)(2)(ii)(G) and 165.528]. The provisions of this subparagraph i shall survive the termination of this Agreement. j. Governmental Access to Records. Business Associate shall make its internal practices, books and records relating to the use and disclosure of Protected Information available to the Secretary of the U.S. Department of Health and Human Services (the "Secretary") for purposes of determining Business Associate and /or Covered Entity's compliance with the Privacy Rule [45 C.F.R. Section 164.504(e)(2)(ii)(H)]. k. Minimum Necessary. Business Associate (and its agents or subcontractors) shall request, use and disclose only the minimum amount of Protected Information necessary to accomplish the purpose of the request, use or disclosure [42 U.S.C. Section 17935(b); 45 C.F.R. Section 164.514(d)(3)]. Business Associate and Covered Entity acknowledge and agree that the definition of "minimum necessary" is in flux and shall keep themselves informed of guidance issued by the Secretary with respect to what constitutes "minimum necessary." 1. Notification of Breach. During the term of the SLA, Business Associate shall notify Covered Entity, as soon as practicable after discovery, of any suspected or actual breach of security, intrusion or unauthorized use or disclosure of PHI of which Business Associate becomes aware. m. Breach Pattern or Practice by Covered Entity. Pursuant to 42 U.S.C. Section 17934(b), if Business Associate knows or learns of a pattern of activity or practice of Covered Entity that constitutes a material breach or violation of Covered Entity's obligations under the SLA, this Agreement or other arrangement, Business Associate shall take reasonable steps to cure the breach or end the violation or cause Covered Entity to cure the breach or end the violation. If the steps are unsuccessful, Business Associate is legally obligated to terminate the SLA or other arrangement if feasible, or if termination is not feasible, report the problem to the Secretary of DHHS. Notwithstanding anything to the contrary in the SLA, Business Associate shall not be liable for any damages suffered by Covered Entity as a result of the termination of the SLA to satisfy this obligation. 3. Obligations of Covered Entity. Covered Entity shall promptly notify Business Associate, in writing and in a timely manner, of any of the following: a. Changes in the form of notice of privacy practices ( "NPP ") that Covered Entity provides to individuals pursuant to 45 C.F.R. Section 164.520, and provide Business Associate a copy of the NPP currently in use. b. Changes in, or withdrawal of, the consent or authorization provided to Covered Entity by individuals pursuant to 45 C.F.R. Sections 164.506 or 164.508. c. Any arrangements permitted or required of Covered Entity that may impact in any manner the use and /or disclosure of Protected Information by Business Associate under the SLA or this Agreement, including but not limited to, restrictions on use and /or disclosure of Protected Information as provided for in 45 C.F.R. Sections 164.522. 4. Termination a. Material Breach. In the event that Covered Entity determines Business Associate has materially breached this Agreement, Covered Entity shall provide an opportunity for Business Associate to cure the breach or end the violation. If Business Associate does not cure the breach or end the violation within a reasonable time, Covered Entity may terminate this Agreement. [45 C.F.R. Section 164.504(e)(2)(iii)]. b. Effect of Termination. Upon termination of the Contract for any reason, Business Associate shall, to the extent feasible, return or destroy all Protected Information that Business Associate or its agents or subcontractors still maintain in any form, and shall retain no copies of such Protected Information. If return or destruction is not feasible, as determined by Business Associate, Business Associate shall continue t� extend the protections of Section 2 of this Agreement to such information, and limit further use of such PHI to those purposes that make the return or destruction of such PHI infeasible [45 C.F.R. Section 164.504(e)]. 5. Amendment to Comply with Law. The parties acknowledge that state and federal laws relating to data security and privacy are rapidly evolving and that amendment of the SLA or this Agreement may be required to provide for procedures to ensure compliance with such developments. The parties specifically agree to take such action as is necessary to implement the standards and requirements of HIPAA, the HITECH Act, the Privacy Rule, the Security Rule and other applicable laws relating to the security or confidentiality of PHI. Upon the request of Business Associate, Covered Entity agrees to promptly, an in no case later than thirty (30) days from Business Associate's request, enter into an amendment to this Agreement embodying written assurances consistent with the standards and requirements of HIPAA, the HITECH Act, the Privacy Rule, the Security Rule or other applicable laws. 6. No Third -Party Beneficiaries. Nothing express or implied in this Agreement is intended to confer, nor shall anything herein confer, upon any person other than Covered Entity, Business Associate and their respective successors or assigns, any rights, remedies, obligations or liabilities whatsoever. 7. Effect on SLA. Except as specifically required to implement the purposes of this Agreement, or to the extent inconsistent with this Agreement, all terms of the SLA shall remain in force and effect. 8. Interpretation. This Agreement shall be interpreted as broadly as necessary to implement and comply with HIPAA, the HITECH Act, the Privacy Rule and the Security Rule. The parties agree that any ambiguity in this Agreement shall be resolved in favor of a meaning that complies and is consistent with HIPAA, the HITECH Act, the Privacy Rule and the Security Rule. 9. Counterparts. This Agreement may be executed and delivered (including by facsimile or Portable Document Format (PDF) transmission) in one or more counterparts, all of which will be considered one and the same agreement and will become effective when one or more counterparts have been signed by each of the parties and delivered to the other party. Any such facsimile documents and signatures shall, subject to applicable legal requirements, have the same force and effect as manually- signed originals and shall be binding on the parties hereto. TC- 3923 - 080111 Employer Initial 1 'll` TASC 29 Last Employer Offer Three year Per employee 2012 2013 2014 Cost One time payment $ 500 COLA2% $ 1,103 $ 1,125 Insurance Contribution $ 300 $ 300 Boot Allowance $ 25 $ 25 Uniform Allowance $ 500 $ 1,428 $ 1,450 $ 3,379 PTO Carryover balance Hours 216 224 New hires cannot take unused insurance contribution as pay Proposed Mediation Settlement Per employee 2012 2013 2014 One time payment on October 15 payroll 450 COLA 2% 1103 1125 Insurance Contribution 300 300 Boot Allowance Increase 30 30 Uniform Allowance Increase 50 50 $ 450 $ 1,483 $ 1,505 $ 3,439 PTO Carryover balance Hours 216 224 New hires cannot take unused insurance contribution as pay Three -year Cost difference per employee from last offer $ 60 The added cost of the Mediation Settlement proposal for three staff positions currently covered by the agreement is: $180 I recommend approving the contract for three years with the changes noted in the proposed Mediation Settlement. Dallas Larson, Administrator September 21, 2011 30