CCR2002267COMMON COUNCIL - CITY OF MUSKEG0
RESOLUTION #267-2002
APPROVAL OF AMENDMENT TO FLEXIBLE BENEFITS PLAN
WHEREAS, The City of Muskego adopted Reso. #112-2002 on May 28,2002, adopting
a Flexible Benefits Plan (consisting of the flexible benefits plan document, the Adoption
Agreement, and component benefit plans and policies) effective June 1, 2002; and
WHEREAS, Said resolution resolved that after January 1,2003, the City would combine
the Plan with the existing Premium Only Cafeteria Plan; and
WHEREAS, The Finance Committee has recommended approval of the attached
amendment to the Flexible Benefits Plan, which incorporates the existing Premium Only
Cafeteria Plan into the Flexible Benefits Plan.
NOW, THEREFORE, BE IT RESOLVED That the Common Council of the City of
Muskego, upon the recommendation of the Finance Committee, does hereby adopt the
attached amendment to the Flexible Benefits Plan.
BE IT FURTHER RESOLVED That the Premium Only Cafeteria Plan adopted on
February 28, 1989 and amended on September 26, 1989 is hereby repealed.
DATED this 10th DAY OF DECEMBER, 2002
SPONSORED BY:
FINANCE COMMllTEE
Ald. Rick Petfalski
Ald. Nancy Salentine
Ald. Patrick A. Patterson
This is to certify that this is a true and accurate copy of Resolution #267-2002 which
was adopted by the Common Council of the City of Muskego.
P4 6
1 1 /02jm
11-26-02
CITY OF MUSKEG0
DAWN GUNDERSON KELLY
W182 S8200 RACINE AVE
MUSKEGO, WI 53150
Dear DAWN GUNDERSON KELLY:
We are pleased you've chosen AFLAC@s FLEX ONE' to help you meet your cafeteria plan needs.
Enclosed in this packet are the forms necessary to amend your FLEX ONE" cafeteria plan documents.
1) Adoption Agreement - The enclosed Adoption Agreement should be executed and
filed as an amendment to your existing plan documents.
2) Corporate Resolution - This resolution should be executed (if applicable) and filed
as an amendment to your existing plan documents.
3) Summary Plan Description Introduction - One copy should be distributed to
each eligible employee (regardless of whether they actually choose to participate)
and the original filed as an amendment to your existing plan documents.
Please disregard any enclosed pages that do not pertain to your requested change,
We value you as a customer of AFLAC Administrative Services/FLEX ONE' If you have any questions or
if we may be of further service, please call us toll-free at 1-800-323-5391 Our customer service specialists
are here to assist you Monday through Friday from 8:30 a.m. to 7:OO p.m. Eastern Time. Please note that
we also provide 24-hour access to your plan information through our toll-free IVR system at
1-877-FLEX-IVR (1-877-353-9487).
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ADOPTION AGREEMENT FOR CITY OF MUSKEGO
FLEXIBLE BENEFITS PLAN
ESTABLISHMENT OF THE PLAN
The Employer named below established as set forth herein, a Flexible Benefits Plan (the "Plan") as of the Effective Date
conslsting of this Adoption Agreement, the Plan Document and the Benefit Plans and Policies specifically referred to herein
including the Dependent Care Expense Reimbursement Plan andlor a Medical Care Expense Reimbursement Pian. The
purpose of the Flexible Benefits Plan is to provide eligible employees a choice between cash and the specified welfare benefits
described in this Adoption Agreement. Pre-tax premium elections under the Plan are intended to qualify for the exclusion from
income provided in Section 125 of the Internal Revenue Code of 1986.
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EMPLOYER INFORMATION
1) Name and Address of Employer1 CITY OF MUSKEGO
Plan Administrator:
WIBZ S8200 RACINE AVE
DAWN GUNDERSON KELLY
Employer's Telephone Number:
MUSKEGO, WI 53150
Employer's Federal Tax ID Number: 39-6006023
(262) 670-5610
125 Start Date:
Effective Date of the Pian:
06/01/02
01/01/03
Subsequent Plan Years:
Last Day of the Plan Year: 12/31/03
01101-12131
Name and Address of the Plan CLAIMS PROCESSOR: FLEX ONE
Service Provider: 1932 WYNNTON ROAD
COLUMBUS, GA 31999
Name and Title of Registered Agent
for Servlce of Legal Process:
LINDER 8 MARSACK, S.C.
AlTORNEYS AT LAW
Affiliated Employers which will Participate in the Pian:
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10) Employer's Type of Business: OTHER
All Employees employed by the Employer shall be eligible to participate under the Plan QX.& the following: (Describe)
TEMPORARY/SEASONAL, PT WORKING LESS THAN 20 HRS WK
An eligible Employee may become a Participant in the Plan:
( ) Immediately. upon the first day of employment (but not prior to the Effective Date of the Pian). e
( ) On the day following commencement of employment.
( X ) On the first day of the month followlng 30 days of employment.
( ) OTHER
ELlGlBiLlTY
provided the Employee completes a Salary Redirection Agreement. However, eligibility for coverage under any given
Benefit Plan or Policy shall be determined by the terms of that Benefit Plan or Policy, and reductions of the Employee's
Compensation to pay Pretax or After-tax Premiums shall commence when the Employee becomes covered under the
An eliglble Employee may become a Participant in the Dependent Care and/or Medical Expense Reimbursement Plan@) (if
applicable Benefit Plan or Policy.
elected below):
( ) On the same day such Employee is eligible for the Pre-Tax Premium benefits under the Plan.
( ) On the day following commencement of employment.
( ) OTHER
( ) On the first day of the month following days of employment.
.. provided the Employee completes a Salary Redirection Agreement selecting such benefits.
The Employer elects to offer to eligible employees the following Benefit Plans and Policles subiect to the terms and conditions of
BENEFITS PROVIDED UNDER THE PIAN
the Pian. These component Beneit Plans .and Pollcies are spiclfically incorporated herein by reference. The maxlmum Pre-tax
Premiums a Participant can contribute via the Salary Redirection Agreement is the aggregate cost of the applicable Benefit Plans
or Policies selected mlnus any Non-elective Contribution made by the Employer. It is intended that such Pretax Premium
accounts shall, for tax purposes, constitute an Employer contribution, but may constitute Employee contributions for State
insurance law purposes. Copies of the Benefit Plans or Policies (or a list of eligible Policy numbers) shall be attached as an
appendix to this Plan.
(X) 1 XI
Group Medical Coverage
Vision Care Coverage
Disability Income-Short Term (A&S)
Grouo Dental Coveraoe
Cancer Insurance
Group Term Life lnsuknce
Disability Income-Long Term (LTD)
Accident Insurance
Intensive Care Insurance
Hospital Indemnity Insurance (HIP)
Specified Health Event
Personal Sickness Indemnity (PSI)
Medical Care Expense Reimbursement described in Section 5.01(b) of the Plan, not to exceed $ 2,500 per Plan Year
pursuant to the CITY OF MUSKEG0
Medical Care Expense Reimbursement Plan.
Dependent Care Expense Relmbursement described in Section S.Ol(c) of the Plan not to exceed $5,000 per Plan Year or
$2,500 for married filing separate returns pursuant to the CITY OF MUSKEG0
Dependant Care Expense Relmbursement Plan.
Opt-out Option: Additional taxable compensation for certain partlclpants who opt-out of certain coverages (as descrlbed
In enrollment materials).
The Employer selects the following Funding Agent for the Plan (check one):
THE FUNDING AGENT
a The Employer, which will comply with the requirements of Sectlon 7.02 of the Plan
The Flexible Beneflts Trust created concurrently wlth the execution of the Plan, which shall receive contrlbutlons under
the Plan in accordance with Section 7.03 of the Plan.
Administrative Expenses incurred in operating the Plan shall be paid by (check one):
ADMINISTRATIVE EXPENSES
The Employer, except as otherwise noted in the Plan,
P The Participants. except as otherwise noted in the Plan.
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0 As evidenced by the formal execution of this Adoption Agreement. the undersigned Employer adopted and established this Plan on
the Effective Date as the Flexible Benefits Plan of the undersigned Employer. In dolng so, the undersigned Employer
acknowledges that this Adoption Agreement and this Plan are important legal instruments with significant legal and tax implications.
The Employer also acknowledges that it has read this Adoption Pgreement and the Plan in their entirety, has consulted
to the extent wnsldered necessary, and accepts full responsibility for participation of employees hereunder and the operation of the
Independent legal and tax counsel other than representatives of.American Family Life Assurance Company of Columbus (AFLACQ).
all filing, reporting and disclosure requirements Imposed by the Department of Labor, lntemal Revenue Service. or any other
Plan. The Employer acknowledges that as Plan Sponsor and the Plan Administrator. it shall have sole responsiblllty to comply with
government agency. specifically including. but not limited to, creating and filing Form 5500s and preparing and distributing
the Plan as necessary to ensure compliance with applicable tax. labor, and other laws and regulations. Employer acknowledges
Summary Plan Descriptions. Furthermore. the Employer further acknowledges that it shall bear sole responsibiltty for amending
receipt of the checklist of Plan Sponsor Responsibilties included in the Plan Document Request tom and has agreed to the
obligations set forth therein.
k is also understood and agreed that American Family Life Assurance Company of Columbus (AFLAC) and its Subsidiaries, agents,
and representatives, are not providing legal or tax advice to the undersigned Employer in connection with this Pian and that no
representations, are made by k with respect to the operation of the Flexible Benefits Plan pursuant to the sample documents
provided by American Family Life Assurance Company of Columbus (AFLAC) to the Employer.
This Pian shall be construed end enforced according to the Internal Revenue Code of 1986. as amended from time to time. the
applicable regulations thereto and the laws of the State of the principal place of business of the Employer.
IN WITNESS WHEREOF, the Employer has caused this Plan and Adoption Agreement to be executed on the day of
bEC. 11 lob2 to rati the adoption of the Plan adopted and effective as of the Effective Date.
WITNESS:
Employer: CITY OF ~WSKEGO
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RESOLUTION ADOPTING A FLEXIBLE BENEFITS PLAN
I - -Thundersigned hereby certifies that the following described Resolution was officially and legally adopted at the duly authorize
forth below.
omciaiheetng of the body with legal authority (hereafter "Authority") to pass said Resolution. Said meeting was held on the date
WHEREAS, the Authority wishes to adopt a cafeteria pian within the context of Section 125 of the Internal Revenue Code for the
benefn of the employets eliglble employees.
benefits plan dowment, the Adoption Agreement. and component benefit plans and Policies) for the Employer named herein below
NOW, THEREFORE, BE IT RESOLVED, that the Authority hereby adopts the Fledble Benefits Plan (consisting of the fteAbie
effective as of the date specified in the Adoption Agreement.
RESOLVED FURTHER, that any officer of the employer may, without a further resolution, execute the Adoption Agreement and any
related documents or amendments which may be necessary or appropriate to adopt the plan or maintain its compliance with
applicable Federal, State and local law.
0
Name:
Body Wlth Legal Authortty of Employer To Pass Resolution:
(Examples ~ Board of Directors. Board of Commissioner. etc.)
Dale of Official Meeting of Authority
at which Resolution was Legally Passed:
Corporate ORlcer
[ OFFICW SEAL]
Signature of Person wlth Authority to Certify that
Resolution was Legally Passed
Print Name and Title of Person above
Date:
'Note: Legal requirements for a valid Board of Directors Resolution vary from State to State. This document is merely a suggested
form. Each Employer should consult with its own legal counsel toensure compliance with applicable law.
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FLEXIBLE BENEFITS PLAN SUMMARY PLAN DESCRIPTION FOR:
CITY OF MUSKEGO
1) Name and Address of Employer1
Plan Administrator:
2) Employer's Telephone Number:
4) Pian Number Assigned to Cafeteria
3) Employer's Federal Tax ID Number:
Plan (e.g.. 501 if thls is the first ERISA
plan number assigned):
5) 125 Start Date:
6) Effective Date of the Plan:
7) Last Day of the Plan Year:
8) Name and Address of the
Subsequent Plan Years:
Pian Service Provider:
9) Name and Title of Registered Agent
for Service of Legal Process:
FLEXIBLE BENEFITS PLAN
EMPLOYER INFORMATION
CITY OF MUSKEGO
DAWN GUNDERSON KELLY
W182 58200 RACINE AVE
(262) 679-5610
MUSKEGO, WI 53150
39-6006023
06/01/02
01/01/03
12131/03
CLAIMS PROCESSOR: FLEX ONE
01/01-12/51
COLUMBUS, GA 31999
1932 WYNNTON ROAD
Al7ORNEYS AT LAW
LINDER a MARSACK. S.C.
10) Affiliated Employers which will participate in the Pian:
11) Employer's Type of Business OTHER
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All Employees employed by the Employer shall be eligible to particlpate under the Pian a€Z.Ll the following:
TEMPORARWSEASONAL, PT WORKING LESS THAN 20 HRS WK
An eligible Employee may become a Participant In the Plan:
( ) Immediately, upon the first day of employment (but not prior to the Effective Date of the Plan).
( ) On the day following commencement of employment.
( X ) On the first day of the month following 30 days of employment.
( ) OTHER
ELIGIBILITY
provided the Employee completes a Salary Redirection Agreement. However, eligibility for coverage under any given
Benefit Plan or Policy shall be determined by the terms of that Benefit Plan or Policy, and reductions of the Employee's
Compensation to pay Pre-tax or After-tax Premiums shall commence when the Employee becomes covered under the
applicable Beneflt Plan or Policy.
An eiialble EmDiOVee mav become a Participant in the Dependent Care and/or Medical Expense Reimbursement Plan@) (If I, electei below):
( ) On the same day such Employee is eligible for the PreTax Premium benefits under the Plan
( ) On the day following commencement of employment. I I On the first day of the month following days of employment. i ) OTHER ~~
orovlded the Emoiovee WmDletes a Salew Redirection Agreement selecting such benefits
~ ~ ,, BENEFiTS PROVIDEDUNDER THE PGN
The following Benefit Plans and .Policies subject to the terms and conditions of the Plan are avallable for election by ellglble
employees. The maximum a participant can contribute via the Salary Redirection Agreement is the maximum aggregate cost of
the Benefit Plans or Poiicles elected minus any Non-elective Contribution made by the employer. It is intended that such Pretax
Premium amounts shall, for tax purposes, constitute employer contribution, but may constitute employee contributions for State
appendix to thls Plan.
insurance law purposes, Copies of the Benefit Plans or Policies (or a list of eligible Policy numbers) shall be attached as an
( X ) Group Medical Coverage
( X ) Vision Care Coverage
( ) Disability incomeShort Term (ABS)
( X ) Cancer insurance
( X ) Group Dental Coverage
( ) Group Term Life lnsurence
( ) Disability Incomelong Term (LTD) ( ) Intensive Care Insurance
( X ) Accident Insurance e
( ) Hospital Indemnity insurance (HIP)
( ) Specified Health Event
( X ) Personal Sickness Indemnity (PSI)
( X ) Medical Care Expense Reimbursement described in Sectlon 5.01(b) of the Plan, not to exceed $ 2,500 per Plan 'fear
oursuant to the CITY OF MUSKEG0 r~~~~ Medical Care Expense Reimbursement Plan.
I X neoendent Care Exoense Reimbursement described in Section 5.01(c) of the Pian not to exceed $5,000 per Plan Year 01 I __, _.r _~~r~~~~~ ~~
$2,500 for married filing separate returns pursuant to the CITY OF MUSKEGO
Dependent Care Expense Reimbursement Pian.
( ) Opt-out Option: See enrollment material.
The Employer selects the following Funding Agent for the Plan (check One):
JHE FUNDING AGENT
P The Employer, which will comply with the requirements of Section 7.02 of the Plan
The Flexible Benefits Trust created concurrently with the execution of the Plan, which shall receive contributions under , the Plan in accordance with Section 7.03 of the Pian.
ADMINISTRATIVE EXPENSES
Admlnlstrative Expenses Incurred in operating the Pian shall be paid by (check'one):
0 The Employer. except as otherwise noted in the Plan.
0 The Participants, except as otherwise noted in the Plan
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