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HomeMy WebLinkAboutEflexTRANSIT2012 ie IexTR _ T Adoption Agreement As set forth below, the following employer hereby adopts the eflexgroup.com (eflex)Transportation Plan (the plan)and engages eflex to provide services related to the plan.The plan is a"Transportation Plan"as defined in Section 132 of the Internal Revenue Code. Fax completed form to eflexgroup Sales at(608)237-3800 or email to efgsales @eflexgroup.com. Note: Incomplete agreements cannot be processed. Please call eflexgroup Sales at(877)933-3539 with questions regarding this agreement. Organization Information `�, Name of Organization: C 1}Li 0-P L�.>J�k.a Enter the name exactly as it appears on your tax returns and as you would like it to appear in your plan documents. Federal ID#: 3Q^- LoOQ 55(03 Date incorporated/organized:. Mailing address: t'Q 1icX 3C� City: (\5h Kosh State: L-i.)I ZIP: L5-4903 Street Address: cg I.5 Chi LYC h AtIP_ State:_j ZIP: c5Z]90 / (if different from mailing address) Organization Type: (Please check all that apply) ❑ Professional Association ❑ Subchapter"S"Corporation* ❑ Non-profit ❑ Subchapter"C" Corporation ❑ Partnership/LLP** ❑ Sole Proprietorship** g Government Agency ❑ LLC(Limited Liability Company)*" ❑ Other: The employer/Organization entity is organized pursuant to the laws of the State of: LIJI0C.brli5 1 Nature of the Business: Lccc \ 'Muni C ►pal l A-9 Phone Number: (qu 2310- 5 I 1 0 SIC: Web Address: T.111 JI.J•C'.i• O t 1(.11511-w i• U5 Contact Information (� Payroll Contact(name and title):Sarah Oe11.xaei Peu 'col Coorcli(-Na{or Phone Number:(}2.6) 231 " 5 1 13 Fax Number: ( ?L6 23LA- 5090 Email: &" _ i a .L° • . r t •-C S as . (1. Human Resources Contact(name and title): enn.14 c 1Ekee i i nsP r/1 Ma))Phone Number:(q 2.6) 2..& 5138 Fax Number:Ma)) 2 3 - sogo Email: ec.ea'tnc�e�re..-G •C` sh1c h• Lo∎•u5 ©2010 eflexgroup,Inc. •2740 Ski Lane•Madison, WI 53713 Phone:877.933.3539•Fax:608.237.3800 •www.eflexgroup.com eflexgroup 00081-15-0910 1 Plan Elections Plan Year Plan Begin Date: 1 \ 1 ' 2.01 2 Plan End Date 12_\ \ \ 2h 12 Number of eligible employees: 515 This agreement shall automatically renew indefinitely for like Terms, unless terminated earlier as set forth in the"Term and Termination" section detailed in this document. Eligibility Requirements To enroll in the plan, an employer must timely submit to eflex a properly completed enrollment spreadsheet for the applicable plan Year.An employee must satisfy the eligibility rules for the benefits as follows(check one): ❑ All Employees are Eligible(including part time): For the Transit and Parking section of the plan, all employees are eligible, regardless of how few hours they work. g Other Requirements(e.g., class, union).To participate in the plan, an employee must: 1 cm*1Z a min ml r+•,,f,C 7 (4 h *i r,4) par wen Kr / /21X1 per vac Plan Participation Participation in the plan begins(check one) ❑ Date of hire. I' First of the month following: ❑ Date of Hire V 30 days ❑ 60 days ❑ 90 days ❑ Other g Other(describe any specific participation requirements): LL °A r �. Benefits Rif Transit Expenses V Parking Expenses Roll over ❑ Remaining funds will roll over from year-to-year. [Remaining funds will be forfeited at the end of the plan year. Contributions R(The employer shall make no additional contributions to the plan. ❑ Employer shall make additional contributions to the plan as described below (describe amounts and terms): ©2010 eflexgroup,Inc. •2740 Ski Lane•Madison, WI 53713 Phone:877.933.3539•Fax:608.237.3800 •www.eflexgroup.com eflexgroup 00081-15-0910 2 • Deductions and Payment Limitations ,/� Are all employees paid on the same schedule? R Yes ❑ No Employees are paid on the following schedule(check all that apply): ❑Weekly(48 pay periods) First pay date after effective date: ❑Weekly(52 pay periods) ❑ Bi-weekly(24 pay periods) First pay date after effective date: 1 15 261 Z [/Bi-weekly(26 pay periods) ❑ Semi-monthly First pay date after effective date: Second pay date after effective date: ❑ Monthly First pay date after effective date: ❑ Other First pay date after effective date: Deductions are taken: ❑ Every time the employee is paid [Other: y C'hL' 'Lk..,ese4pt lit pC'rn Ehe..re. l J c 3( c)c innift • (Example:monthly payroll paid on the 15 and 30 of month unless the dates fall on a weekend or holiday.) Enrollment Enrollments will be sent on the eflex spreadsheet(no charge). ❑ Paper enrollment($2 fee per enrollment form). ❑ Internet Enrollment. Employer provides a list of eligible employees and chooses timeframe for employees to enroll online.This option requires 14 business days for set up. Contact eflex Sales at efgsales(c�eflexgroup.com to arrange online enrollment. Funding Please choose one of the following funding options. Mr Payroll Deduction Funding.Your account administrator will send you a payroll deduction report three business days prior to your payroll. You will verify deductions and return any corrections to your account administrator prior to your payroll date. ACH funds are drawn on the payroll date and occur within 24-48 hours from the payroll date depending on bank clearing time. ❑ Claims Based Funding.Your account administrator will send you a claims summary report based on your processing schedule. Funds will be drawn via ACH two business days after you(the employer)receive the report. Please make your employees aware of the claims-based schedule you have chosen with your plan so they will know when to expect reimbursements. Monthly Administration Fees eflex will invoice monthly;fees will be debited on the 10th of each month. ©2010 eflexgroup,Inc. •2740 Ski Lane Madison, WI 53713 Phone:877.933.3539•Fax:608.237.3800 •www.eflexgroup.com eflexgroup 00081-15-0910 3 Billing Information /� Billing Contact(name and title): -3 e� Uc ArePaini3e_cl ('be ne. 1 e.y_ rd;ncbr Email address for monthly invoices:6fenintrv3p f � ei• C�h • (.t\t' 1l�5 Banking Arrangements Please attach voided check. Do not use a deposit slip as the number could be invalid.Your agreement will not be processed without a voided check. Bank Account Information L� Bank Name: ASSc)G 0 ( )x u n V x n1( L(Y S 11..e o, O►C oc Bank Address: 44y i\ Sal illae1l ST. City: aally q�h State: U)Z ZIP: Q01 Name on the Account: ►k-4 p T osh Itc sh Routing and Transit#: �i���5g30.51 S Account#: \ \ Fl 0 8 )5 n Name of person signing check(please print): 1 .Cn1 ��eerO lamm r itutvock 2 5: aa Al trout . We authorize eflex, hereinafter called COMPANY, to initiate debit entries to ?S�I'd Lati . our checking account indicated above and the depository named above, hereinafter called DEPOSITORY, to debit the same to such account.This , authority is to remain in full force and effect until COMPANY and DEPOSITORY has received written notification from either of us of its `} � � �� �� termination in such time and in such manner as to afford COMPANY and .... W- DEPOSITORY a reasonable opportunity to act on it. Fees — see_ A\ac\-e t 't n t#1t ei m u. Annual Fee $ ❑ Go Green, Save Green Option. We agree to submit all enrollments electronically, include email addresses and secure direct deposit*of reimbursements for 100% of enrolled employees, elect electronic funds transfer(EFT)for all fees and plan funding. In return,we will be charged a discounted per participant per month (pppm)fee of$4.50 including debit card. By electing the Go Green pricing,we understand and agree that we will be charged an additional fee of$3 pppm for each participant who doesn't elect direct deposit and $3 pppm for each participant who doesn't provide eflex with an email address. Monthly Administration Fee(per participating employee) $ Minimum Monthly Fee $ ©2010 eflexgroup, Inc. •2740 Ski Lane Madison, WI 53713 Phone:877.933.3539•Fax:608.237.3800 •www.eflexgroup.com eflexgroup 00081-15-0910 4 Optional Fees Paper enrollment(without electronic spreadsheet) $ NOTE: eflex may increase fees from year to year. If increases are made there will be a notice on your renewal information. Do you have other benefit plan administration with eflex?(check all that apply) ❑ POP ❑ FSA ❑ HSA ❑ HRA ❑ COBRA Items Needed Before Implementation Complete Adoption Agreement(this document)and e-mail to efgsales(@,eflexcgroup.com or fax to 608.237.3800. Incomplete agreements cannot be processed. Please call eflex Sales at 1.877.933.3539, ext. 300 with any questions. Attach a copy of the pricing sheet from your proposal to the completed Adoption Agreement. Complete the enrollment spreadsheet using the eflex format and email to efqsales(@,eflexciroup.com. Responsibilities of the Employer Effect of Agreement This agreement, along with the eflex plan document and any addenda attached to the agreement, contains all provisions of an Internal Revenue Code§ 132 Qualified Transportation Plan adopted by the Employer. This agreement is also a contract between the Employer and eflex.The employer may wish to consult legal counsel before executing this agreement. Plan Sponsor and Administrator The employer is both the sponsor and the administrator of the plan,with the ultimate responsibility for: 1)ensuring that the plan complies with all applicable federal, state and local laws, including Internal Revenue Code§ 132; 2)establishing, amending, terminating, and interpreting plan provisions; and 3)determining whether claims should be paid. Although the employer has engaged eflex to provide certain documents and administrative services(including review and payment of qualified claims under the plan), eflex shall whenever possible, consistent with this agreement, act as directed by the employer. Funding of Plan: (please read carefully) The employer shall provide eflex with all funds that eflex requires to pay benefit claims under the plan. If eflex pays a qualified benefit claim in advance in an amount greater than $100 of receipt of the corresponding funds from the employer, the employer shall provide funds to eflex within 5 days notice of such payment by eflex. If the employer has funded any overages, eflex will review the account on an annual plan year basis, and any overages are refunded with forfeitures. If the necessity arises for eflex to hold the overages in an account,the overages are added at plan year close with other applicable funds. If the employer is under a PEO arrangement or other payroll service, by signing this agreement you authorize the PEO/payroll service to forward funds to eflex as necessary herein. All debit card deposits will roll forward to the next plan year. Funds will be returned upon termination of the employer. Mutual Indemnification Each party shall indemnify the other party, its employees, directors, and agents(collectively, Indemnitees)and hold the Indemnitees harmless against all damages, losses, or other liabilities incurred by the Indemnitees arising from any act or failure to act by the Indemnitor, its employees, directors,or agents in connection with the plan. Such indemnification shall include(and not be limited to)liabilities arising from a failure to timely provide eflex with information. Such indemnification shall also include liabilities arising from administration or interpretation of the plan by either party in a manner contrary to law. •Rlo��►ths�ondi -Wv-above, -the C�4LI� 1 i ab■li A-y Shall be sLby�u he- It mi}�}iat15 Cdr tc.�urted (r 5• 893.8❑, w;5. 3+. +4fe5, and 4■� S;car`►14X' StC ©2010 eflexgroup, Inc. •2740 Ski Lane•Madison, WI 53713•Phone:877.9313539•Fax:608.237.3800 •www.e(lexgroup.com eflexgroup 00081-15-0910 5 Term and Termination The term of this agreement shall be 2 years, and shall automatically renew annually unless the employer gives to eflex notice of termination at least 90 days prior to the plan year end date. In any case of termination,the employer shall be responsible for 90 days of administration fees to cover the administration of claim run out. Other Termination By Employer: If the employer terminates the agreement without giving the notice or terminates within the current plan year specified above,then there shall be a termination fee of 6 months of administration fees, measured by the administration fees averaged over the prior three months, payable to eflex prior to the actual termination date.Additionally, the employer shall be responsible for reimbursing eflex$300.00 and any applicable material and labor costs,as well as any administration fees required to cover the administration of run out claims. Other Termination by eflex:eflex may terminate the agreement effective(1)as of an end of Term date wither the 90-day notice or(2)on a date other than an end of Term date, but only if the employer previously breached this agreement, such as by failing to pay eflex for its services,failing to provide funds for payment of claims, or failing to cooperate with eflex. The employer and eflex executed this Adoption Agreement on the dates set forth below. Employer Company Name: City of Osh'kosh Name: Signature: See Page 6A Date: eflexgroup.com Name: CAX(/1;fi C ( Q 1'V,5"- - Signature: " L . / Date: r/ t/( Agent Information Name: The_ 1ci cf\ Group Finn", nfr Address: 1 Q �.1.�ccy ICS 1 1",f-kh Rt vers lynar Dr, City: bi( a,5i1C1_ State: ZIP: 5(5 I S 3 .. COrn email: • ' G.1.L.' . i' _ 11111 " one Number: ii2) 31-n- aL0o ©2010 eflexgroup,inc. 2740 Ski Lane•Madison, WI 53713•Phone:877.933.3539•Fax:608.237.3800 •www.eflexgroup.com eflexgroup 00081-15-0910 6 Signed for and in behalf of the City of Oshkosh Mail(A. Rohloff, City Manager Pamela R. Ubrig, City Clerk p sz; Peggy t no, Director of Finance �,...� -i��1 t daft `�, n I orenson, Ci y r ttorney I hereby certify that the necessary provisions have been made to pay the liability which will accrue under this contract. 6A Associated Bank December 14,2010 City of Oshkosh P.O.Box 1130 Oshkosh,WI 54903 RE: City of Oshkosh Account Confirmation To Whom It May Concern: This letter confirms that the City of Oshkosh has a checking account with Associated Bank. It is identified as follows: Account#: 1186855 Routing#: • 075900575 If you have any questions,please feel free to give me a call at 920-236-8131. Sincerely, a cP)ex,01 Becky Holland Senior Sales Support Specialist Commercial Banking • - t•C: } j: - 5 tti6; UTri � " g` ,.'L:a• eflexgroup . .,..._..00aoouer-veswrgsttoam,moat,„ I. FLEXIBLE SPENDING ACCOUNT PLAN,FINANCIAL QUOTATION PAGE Implementation Fee(Specify if this is first year only or if it applies upon renewal): $300 annual(waived first year) *Monthly Administrative Fee: 1st Year: $3.75 per participant/mo in the health care reimbursement account only $3.75 per participant/mo in the dependent care reimbursement account only 5 3.75* per participant/mo if enrolled in both health&dependent care reimbursement accounts *Note:We do not charge separately for the FSA and Dependent Care accounts.The monthly PPPM is$4.10 whether participants choose to enroll in only one account or both the FSA and Dependent Care accounts. Transit/Parking is an additional$1 PPPM if elected in conjunction with an FSA/Dependent Care account($5.10 PPPM Total). For a Transit/Parking account only,the PPPM is$4.10. $NO CHARGE per participant/mo if debit card option is selected Fee for additional debit card(s) $INCLUDED-NO ADDITIONAL CHARGE Additional charge(if applicable)for mailing quarterly statements to the participants home: $1.00 EACH Minimum Monthly Billing: $50.00 Postage Charges(if applicable) $INCLUDED 2n°Year: SAME AS ABOVE—FEES GUARANTEED FOR THREE-YEAR CONTRACT 3rd Year: SAME AS ABOVE—FEES GUARANTEED FOR THREE-YEAR CONTRACT Flexible Benefits Administration Solutions for the City of Oshkosh a f!exgrou s" Prepared for The Horton Group 1 I p a g e effexgroup Optional Services and Fees (Please specify if you charge any additional fees that have not otherwise been stated on the Financial Quotation Page) There are no additional fees that have not been stated on the Financial Quotation Page. Date:September 1,2011 Name of Company/Firm: eflexoroup, Inc. Address: 2740 Ski Lane, Madison WI 53713 Telephone Number: Nancy Dantzman Direct: 608-237-3015; Mobile: 608-206-7229 Authorized Signature: Nancy Dantzman Flexible Benefits Administration Solutions for the City of Oshkosh eflexgroup Prepared for The Horton Group 2 1 p a g e