Resolution No. 97711
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RESOLUTION NO. 9771
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
VERNON APPROVING AND AUTHORIZING THE EXECUTION OF
AN ADMINISTRATIVE SERVICES AGREEMENT WITH IGOE &
COMPANY INCORPORATED, DBA IGOE ADMINISTRATIVE
SERVICES, REGARDING THE CITY'S FLEXIBLE BENEFIT
PLAN
WHEREAS, the City of Vernon had an agreement with Igoe &
Company Incorporated dba Igoe Administrative Services ("Igoe") to
provide administrative services for the Flexible Benefit Plan (the
"FSA") for the period January 1, 2008 through December 31, 2008; and
WHEREAS, the City Council of the City of Vernon desires to
renew the FSA for the period January 1, 2009 through December 31,
2009, and authorize the payment of fees in the approximate sum of
$2,700.00 plus additional services as requested; and
WHEREAS, Igoe has provided an Administrative Services
Agreement (the "Agreement") that incorporates the terms and conditions
of the Renewal; and
WHEREAS, the City Council desires to approve the Agreement
with Igoe for administration of the FSA.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE
CITY OF VERNON AS FOLLOWS:
SECTION 1: The City Council of the City of Vernon hereby
finds and determines that the recitals contained hereinabove are true
and correct.
SECTION 2: The City Council of the City of Vernon hereby
approves the Administrative Services Agreement with Igoe, in
substantially the same form as the copy which is attached hereto as
Exhibit A and incorporated by reference.
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SECTION 3: The City Council of the City of Vernon hereby
authorizes the Mayor or Mayor Pro-Tem to execute said Agreement for,
and on behalf of, the City of Vernon and the City Clerk is hereby
lauthorized to attest thereto.
SECTION 4: The City Council of the City hereby authorizes
the City Administrator, or his designee, to make whatever non -
substantive, administrative and/or text changes, upon advice of
counsel, to the Agreement.
SECTION 5: The City Council of the City of Vernon hereby
directs the City Clerk, or her designee, to send a fully executed
Agreement to:
IGOE Administrative Services
Attn. Michael C. Igoe, President & CEO
16769 Bernardo Center Drive, Suite 21
San Diego, CA 92128-2548
SECTION 6: The City Clerk of the City of Vernon shall
certify to the passage of this resolution, and thereupon and
thereafter the same shall be in full force and effect.
APPROVED AND ADOPTED this 24th day of November, 2008.
ATTEST:
MANtELA GIRON,—CkLty Jerk
Name: Leonis Co Malburg
Title: Mayor /r^
- 2 -
1 STATE OF CALIFORNIA )
2 ) ss
COUNTY OF LOS ANGELES )
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4 I, MANUELA GIRON, City Clerk of the City of Vernon, do hereby
5 certify that the foregoing Resolution, being Resolution No. 9771, was
6 duly adopted by the City Council of the City of Vernon at a regular
7 meeting of the City Council duly held on Monday, November 24, 2008, and
8 thereafter was duly signed by the Mayor Pro-Tem of the City of Vernon.
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11 MANUELA GI N, City Clerk
12 (SEAL)
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EXHIBIT A
ell,
�16m
ADMINISTRATIVE SERVICES
September 24, 2W8
Ms. Karina Rueda
City of Venison
4305 Santa Fe Ave.
Ve", CA 90058
RE; FLEXIBLE BENEFIT PLAN ADMINIsTRAT1VE SERVICES AGRr;gMENT/RENEWAL
Dear Ms. Rueda
Igoe Administrative Services is excited to offer another year of administration on your current Flex account! Outlined on the
following pages is a summary of your current plan demon and administration, as well as a new Administrative Services
Agreement for your review. Please review this information carefully to ensure that everything is correct. If you wish to make any
plan design/administrative chances, please indicate such in all appropriate sections. Once this information is received a new
Administrative Services Agreement will be forwarded to you.
The following items are required in order to complete the renewer process:
1. A fully executed copy of the Administrative Services Agreement (ASA). 6y signing the attached ASA, please note that
you are also affirming all plot design/administrative information included in your, renewal packet. Please do not sign
the attached ASA if you wish to make any changes to your plan design or administration.
A list of all pay dates that will have a salary redirection during the upcoming plan year.
3. Payment for renewal services. All administrativeypv W;Z.must be made via-ACH if you do not hold a bank account
Upon receipt of all Items listed above, your Igoe Account Management Team will forward you new enrollment materials and
contact you to coordinate the timing of your new enrollments. Please keep in mind that it may take up to 10 business days for
Igoe to process the attached paperwork.
We would appreciate the opportunity to discuss your plan year renewal. Your Account Management Team will be contacting you
shortly to make recomrhenderions on service options that may benefit your current administration.
We thank you for your continued business and look forward to another year of partnership.
Sincerely`
Michael C. Igoe
Presi lent & CEO
Enclosures
cc: Brenda Lee (Gallagher Benefit Services, Inc.)
ca Allyn Heck (Gallagher Benefit Services, Inc.)
16769 8em0rdo Center DW9, 4ub,21 San Dingo, CA 92IW2548
858-673-X70 8004"18 Fax ND.858473.3666 888-3574307wwwooi000.com
IGOE'
ALIIVIINISTRATIVE 5Er VICES
Please review the current data for your Flex Plan. This will update your client records, enrollment materials, and Plan Documents
keeping your Plan in compliance. Please make changes directly on this form, sign and return to your Account Management Team at
flexgunport0goigoe.corn or via fax at fax: (858) 777-5424.
Section I:_ Demonwhic Information*
Client:
City of Vernon
4305 Santa Fe Ave.
Vemon, CA 90058
(323) 583-8811
Main HR Contact:
Karina Rueda
Telephone:
(323) 583-8B11 ext. 325
E-mail:
krueda@ei.vemon.ca.us
Broker Name:
Brenda Lee
Broker Cc:
Gallagher Benefit Services, Inc.
Telephone:
(818),539-1321
E-mail:
brenda lee@a]g.00m
Entity type:
[ ] C Corporation
(] S Corporation [ ] Non profit [ ] Partnership
] LLC
[ ] LLP [ ] Sole Proprietorship [ ] Union
[Id Government agency
Please indicate if you are a member of an affiliated service group: F] No (J Yes - If "Yes", list all other members of the group:
Please indicate if you are a member of a controlled group: [11 No [ ] Yes - If -Yes', list all other members of the group:
*Changes to this section YAD not prompt a revision of the attached ASA.
Se*Lt 11; Plan Review
Plan;Year: January 1,, 2009 - December 31, 2009
23 Month Grace Period: WA
Plan Year Run -Out End: the last day of February foitowing the dose of the Plan Year
Termination Run-W End: 60 days following the date of termination
ENgibllty to Participate: the first day of the month follow;ng coincident or follovring the date of hire
Cl;taar(fladion: Classified as a full-time employee
Minimum 911111giift Hour: WA
DependentArmuld Maximums
Medkd Annual Maxknuns
t,irllited Purpose FSA vd%oe:
00w h awance Premium Plan:
Tran *i P&*Jng Plan:
Fiscal Year pates
$5,000 ($2,500 marred filing satey)
$5,000
NO
NO
NO
June 30
NOTE: ANY CHANGES TO PLAN DESIGN WILL REQUIRE AN AMENDED & RESTATED PLAN DOCUMENT AT A FEE OF $150.00. ADDITIONALLY, ANY CHANGES
MADE TO THIS SECTION MAY PROMPT A REVISION TO THE ATTACHED ASA.
912412008 AUMINIS1 HAI IVE 5ERVILEy
gjc oq_lli. Mministrati"
Total # of Pay Periods: 27
Paydays? Every Other Thursday
Reimbursement Processing Method: MICR Cheeks
Reimbursement Processing Cycle: Every Other Thursday (same as payday)
PLEASE PROVIDE A LIST OF ALL PAY DATES THAT WILL HAVE A SALARY REDIRECTION DURING THE UPCOMING PLAN YEAR. THIS LIST IS REWIRED IN ORDER
TO COMPLETE THE RENEWAL PROCESS;
CHANGES WADE TO THIS SECTION MAY PROMPT A REYISM TO THE ATTACHED ASA.
Section IV. Enrollment VerNication
Total number of benefit eligible employees: 300
If the above number is incorrect or has changed, please provide the total number of benefit eligible employees as of this notice:
Will open enrollment
k] Yes - list vendor name and contact information
(e.g. BeneTrac, ADP, etc) -
505 NORTH BRAND AVENUE BLVD., SUITE 600, GLENDALE, CA 91203-3944
Will mid year enrollments & changes be communicated from an outside vendor? W No [ ] Yes - list vendor name and contact
information (e.g. BensTrac, ADP, etc) "
be communicated from an outside vendor? [ ] No
**IF OPEN ENROLLMENT/ONGOING FILES WERE NOT PREVIOUSLY APPROVED BY IGOE ADMINISTRATIVE SERVICES, PLEASE FORWARD THE INCLUDED FILE
SPECIFICATIONS TO YOUR VENDOR, ALL FILE TRANSFERS MUST CONFORM TO THE ATTACHED SPECIFICATIONS UNLESS EXPRESSLY AGREED TO IN WRITING BY
ALL PARTIES,
Section V: Authorization
Your signature below is:
❑ Confirmation that all above information Is correct or OW the appropriate changes have been noted above. (Write
corrections directly on the form before returning. Written information will be acted upon. N such documentation,
requires a chop to the included ASA or an addition to your renwaal fees, a revised ASA and renewal invoice win be
provided) - Please sign the attached ASA if no. crmea were made to the above information.
O Admowledgement that Igoe Administrative Services is NOT responsible for massing or incorrect information not noted
above.
L3 Acceptance of the 2009 Plan Year Re -enrollment Pee of $300.00.
0 Agreement that you understand that additional fees apply when:
• Plan changes andfor Corrections that affect the materials are reported after materials have been created for the new Plan
Year -including n"year chang
• Non -Discrimination changes andlor corrections the affect testing results are reported after tests have been run.
• Administrative or Plain Design changes are made - including mWyew chance.
GtieAt
Date
1111712008 AOMINISWATivt SEfivlwi
AUMINISTRATIVE SERVICES
CITY OF VERNON FLEXIBLE BENEFrr PLAN
ADMINISTRATIVE SERVICES AGREEMENT
This Agreement specifies the services to be provided to City of Vernon, in the ongoing administration of the City of Vernon Amended and
Restated Flexible Benefit Plan (the "Plen"PCovered Entity") as well as the specified responsibilities of City of Vernon (the "Plan
Administrator"!"Pian Sponsor") and tgoe Adndnishvdve Services (the "Contract Administrative FirmTBusiness Associate"), The Contract
Administrative Firm ("Business Associate") shall be engaged by the Plan Administrator/Plan Sponsor as a subcontractor in the performance of
administrative services for the Wan.
1. In accordance with the terms of this Agreement, the Contract Administrative Firm shall have the following responsibilities:
A. The Contract Administrative Finn shall provide Flexible Benefit Plan services in accordance with this Agreement, as requested
by the Plan Administrator/Plan Sponsor in connection with the Plan.
B. The Contract Administrative Firm shall consult with Plan Administrator/Plan Sponsor on the design of the Plan.
C. The Contract Administrative Firm shall provide the Plan Administrator/Plan Sponsor with the following sample documentation
in order to initiate the administrative function:
(i) A sample Plan Document for review and potential adoption by Plan Sponsor and Plan Sponsor's legal counsel;
(ii) A master set of Employee Communicallon/Enrollment Materials, including:
a. A Summary Plan Description; and
b. Election Forms to be used during the Enrollment Process; and
C. Reimbursement Request Forms; and
d. Instructions for filing claims for reimbursement and awls procedures.
The Plan Sponsor is not required to adopt or utilize the sample Plan Documents, Enrollment Materials or Forms provided by
the Contract Administrative Finn and may use Its own forms, subject to review by the Contract Administrative Firm. Contract
Administrative Firm makes no warranties or representations regarding the adequacy of such documentation. Additional fees
may apply if additional work is required to process enrollments or reimbursements if the forms submitted by the Plan
Administrator/Plan Sponsor do not comply with the Contract Administrative Firm's requirements.
D. Process Reimbursement Requests, including the provision of written instructions to participants for re -submitting requests in
instances where required information may be missing. In the event of an appeal by a participant, the Contract Administrative
Firm agrees to reimburse expenses based on Anal claims approval provided by the Wan AdministratorRa n Sponsor.
E. The Contract Administrative Punt will use the Plan Administrator/Plan Sponsor's Flexible Benefit Plan checking account or
make other arrangements with such employer, as so directed by the Plan Administrator/Plan Sponsor, in order to process
partippant reimbursements. See Exhibit C. If the benefits card is contracted, the Plan Administrator/Plan Sponsor will fund
that account via ACH transfer directly to the benefits card provider.
F. Provide a check register or similar report to the Plan Administrator/Plan Sponsor for all transactions posted during each
processing period.
G. Conduct Nondiscrimination testing on the 125 Plan(s), based on information provided by the Plan Administrator/Plan Sponsor,
and provide Man Administrator/Plan Sponsor with a written interpretation following each open enrollment period.
H. Provide sample forms for the Plan AdministratodPlan Sponsor to communicate participant terminations and quawN change
in status events to the Contract Administrative Firm.
I. Provide a yearto-date report of account balarrees, reimbursements paid, and scheduled payroll contributions amounts for all
p * enrolled in the Flexible Spending Accounts for each month.
(ISUE
912412008 AWINISTRATIVE '.ikMrES
J. Provide preparation of IRS Form 5500, if applicable, following the close of each Plan Year,
K. The Contract Administrative Firm will attend any audit or hearing held by a government agency or bureau regarding
compliance issues directly pertaining to administration services performed by Contract Administrative Firm during the term of
this Agreement and will provide any and all requested documents in their possession. This provision will survive the expiration
or termination of this Agreement.
2. Business Associate Contract Provisions:
A. All definitions referred to in the Business Associate Contract Provisions of this Agreement shall have the same meaning as
those described in 45 CFR §§ 160.103, 164.103, 164.304 and 164.501.
B. Obligations and Activities of Business Associate in accordance with HIPAA regulations regarding Protected Health Information
(PHI) and Electronic Protected Health Information (EPHI):
(i) Business Associate agrees to not use or further disclose Protected Health Information other than as permitted or
required by the Agreement or as required by law.
(ii) Business Associate agrees to use appropriate safeguards to prevent use or disclosure of the Protected Health
Information other than as provided for by this Agreement.
(iii) Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is known to Business
Associate of a use or disclosure of Protected Health Information by Business Associate in violation of the
requirements of this Agreement.
(iv) Business Associate agrees to report to Covered Entity any use or disclosure of the Protected Health Information not
provided for by this Agreement for which it becomes aware.
(v) Business Associate agrees to ensure that any agent, including a subcontractor, to whom it provides Protected
Health Information received from, created or received by Business Associate on behalf of Covered Entity agrees to
the same restrictions and conditions that apply through this Agreement to Business Associate with respect to such
information.
(vi) Business Associate agrees to make internal practices, books, and records relating to the use and disclosure of
Protected Health Information received from, or created or received by Business Associate on behalf of, Covered
Entity available to the Covered Entity, or at the request of the Covered Entity to the Secretary, in a time and manner
designated by the Covered Entity or the Secretary, for purposes of the Secretary determining Covered Entity's
compliance with the Privacy Rule.
(vii) Business Associate agrees to document such disclosures of Protected Health Information and information related to
such disclosures as would be required for Covered Entity to respond to a request by an Individual for an accounting
of disclosures of Protected Health Information in accordance with 45 CFR §164.528.
(viii) Business Associate agrees to implement any and all administrative, technical and physical safeguards necessary to
reasonably and appropriately protect the confidentiality, integrity and availability of electronic Protected Health
Information that it creates, receives, maintains or transmits on behalf of Covered Entity.
(ix) Business Associate agrees to ensure that access to Electronic Protected Health Information related to the Covered
Entity is limited to those workforce members who require such access because of their role or function.
(x) Business Associate agrees to implement safeguards to prevent its workforce members who are not authorized to
have access to such Electronic Protected Health Information from obtaining access and to otherwise ensure
compliance by its workforce with the Security Rule.
(xi) Business Associate agrees to ensure that any agent, including a subcontractor, to whom it provides Electronic
Protected Health Information (`ePHI") received from, or created or received by Business Associate on behalf of,
Covered Entity agrees to implement appropriate safeguards to protect the ePH I.
(xii) Business Associate agrees to report to Covered Entity, in writing, any security incident of which it becomes aware.
Security incident shall mean successful unauthorized access to, disclosure, modification or destruction of, or
interference with, the Electronic Protected Health Information by a third party, In such instances, Business
Associate shall identify: the date of the security incident, the scope of the security incident, the Business Associate's
response to the security incident and the identification of the party responsible for causing the security incident, if
known.
(xiii) Upon request from Covered Entity, Business Associate agrees to provide information to Covered Entity on
unsuccessful unauthorized access, use, disclosure, modification or destruction of the Electronic Protected Health
Information to the extent such information is available to Business Associate, Business Associate reserves the right
to provide such information on a monthly basis as an aggregate number.
(xiv) As required by the Security Rule, Business Associate agrees to treat a material breach of this Agreement as a
breach of the Agreement and to an early termination of the Agreement by Covered Entity,
clh� "IP
912412008 AOMINtSMAUVE sECtvirEs
C. Permitted Uses and Disclosures by Business Associate
Except as otherwise limited in this Agreement, Business Associate may use or disclose Protected Health Information to
perform functions, activities, or services for, or on behalf of, Covered Entity as specified in this Agreement, provided that such
use or disclosure would not violate the Privacy Rule if done by Covered Entity.
3. The Contract Administrative Firm is willing to perform the services described in this Agreement, provided that Contract Administrative
Firm shall not. assume the responsibilities of the Plan AdministratorlPian Sponsor under the Plan, and provided that Contract
Administrative Firm shall not constitute or be deemed or construed to constitute the "Plan Administrator" of the Plan as such term is
defined in the Plan and within the meaning of ERISA Section 3(16). The Contract Administrative Firm will use reasonable care and due
diligence in the performance of its responsibilities hereunder. In addition, except as expressly set forth herein, the Contract
Administrative Firm shall not be a "fiduciary" of the Plan as such term is defined in ERISA Section 3(21). Plan Administrator/Plan
Sponsor agrees that this responsibility is, and remains, that of the Plan Administrator/Plan Sponsor.
4. In accordance with the terms and conditions of this Agreement, the Plan Administrator/Plan Sponsor agrees to the following;
A. The Plan Administrator/Plan Sponsor desires to engage the Contract Administrative Firm to provide professional services in
accordance with this Agreement, and the Contract Administrative Firm desires to accept such engagement.
B. The Plan AdministratorlPlan Sponsor shall administer the Plan or appoint a person or committee to administer the Plan (the
"Plan Administrator").
C. The Plan Administrator/Plan Sponsor understands and acknowledges that Contract Administrative Firm is responsible only for
providing the services specifically allocated to the Contract Administrative Firm in this Agreement.
D. If using a vendor for electronic enrollment for your group health benefits, the Plan Sponsor/Plan Administrator shall remain
ultimately responsible for the accuracy of the Flexible Benefit Plan elections and all related records. The Plan Sponsor/Plan
Administrator is responsible for capturing all electronic enrollment data and transmitting it to the Contract Plan Administrator
prior to the appropriate effective dates, The Plan Sponsor/Plan Administrator is responsible to review such reports and to
provide corrections as needed. The Contract Plan Administrator will continue to provide all reporting as outlined in this
Agreement.
E. The Plan Administrator/Plan Sponsor agrees to have the sample Plan Documents provided by the Contract Administrative
Firm reviewed and approved by the Plan Sponsor's legal counsel. Upon this review, the Plan Administrator/Plan Sponsor
agrees to supply the executed Plan Documents for review by participants upon request within a reasonable amount of time.
In addition, the Plan Administrator/Plan Sponsor agrees to provide a Summary Plan Description to each participant upon
enrollment in the Plan and to communicate any changes which may be made to the Plan and/or the Summary Plan
Description accordingly.
F. The Plan Administrator/Plan Sponsor shall establish a zero -balance Flexible Benefit Plan checking account or make other
arrangements with such employer in order for the Contract Administrative Finn to process claims for reimbursement under the
Plan (See Exhibit C).
G. The Plan Administrator/Plan Sponsor shall report all participant terminations and all qualifying change in status events In a
written format, including all requested information, to the Contract Administrative Firm prior to the first affected payroll date.
Should this information not be provided In a complete or timely manner, the Plan Administrator/Plan Sponsor agrees to pay
any resulting administrative fees which may be incurred in order to process retroactive adjustments to payroll contributions or
reimbursement claims processed in error.
H. The Plan Administrator/Plan Sponsor shall provide the Contract Administrative Firm, confirmation of redirections into the
Flexible Benefit Plan, based on reports provided by the Contract Plan Administrative Firm, in a timely manner, thus allowing
the Contract Administrative Firm to post contributions for the purpose of processing reimbursements. Should this information
not be received in a complete and timely manner, the Plan Administrator/Plan Sponsor agrees to pay any resulting
administrative fees required to process any retroactive changes, as fees for this service are not covered under this Agreement.
I. The Plan Administrator/Plan Sponsor agrees to provide to the Contract Administrative Firm, upon each open enrollment period
and with each new enrollment in the Plan, all required data to perform IRS -required 125 Plan Non-discrimination Testing. The
Plan AdministratorlPlan Sponsor agrees to report any changes to the Contract Administrator, which may affect the qualification
of the Plan for meeting Non-discrimination requirements. In addition, the Plan Administrator/Plan Sponsor agrees to Initiate
any action required in the event the Plan is reported as discriminatory.
ChklE
912412006 AUMINISTRAUVE SERVICES
J. The Plan Administrator/Plan Sponsor shall retain documentation relating to Plan operations that may be requested in an IRS
or Department of Labor audit of Plan operations - Including, but not limited to: Non-discrimination testing information, executed
copies of the Plan, Salary Redirection Agreements ('Enrollment Forms"), Plan Amendments, Resolutions adopting the Plan,
and Form 5500s, (if applicable), for seven years after the dose of each Plan Year,
K. The Plan Administrator/Plan Sponsor shall ensure that only common law employees participate in the Plan [employees of
companies described in IRC Section 414 (b), (c) or (m) and listed in the Plan as participating affiliates may also participate]
and to ensure that the terms of its Plan Document are properly enforced.
L. The Plan Administrator/Plan Sponsor shall provide all requested information on a timely basis for Igoe Administrative Services
to file an annual Form 5500 Return, if applicable, for the cafeteria plan within seven months following the close of each plan
year. In addition, the Plan Sponsor may be required to provide requested information in order for Igoe Administrative Services
to file Form 5500 Annual Returns for the component benefit plans offered through the cafeteria plan, (component benefit plans
would be a multiple plan including Premium Conversion Plans, Dependent Care. FSA and/or Medical FSA).
M. The Plan Administrator/Plan Sponsor shall provide the required information on a timely basis ,in order for Igoe Administrative
Services to perform Non-discrimination testing required by the Internal Revenue Code for 125 Plan(s) (including, but not
limited to: ensuring that a non-discriminatory classification of employees is eligible for the plan, that contributions and benefits
do not discriminate in favor of highly compensated employees, and that no more than 25% of the total pre-tax benefits is
received by officers and owners). Additional information may be required in order for Igoe Administrative Services to conduct
Non-discrimination testing for the component benefits offered through the cafeteria plan (including insurance and flexible
spending account benefits). Igoe Administrative Services will perform Non-discrimination testing shortly after enrollment.
N. At each month -end the Contract Administrative Firm will submit a statement showing the amount of fees for that month
pursuant to Exhibit A. The Plan Administrator/Plan Sponsor will pay the Contract Administrative Firm the full amount via ACH
debit or via payment directly from the account utilized by the Contract Plan Administrative Firm for the payment of Flexible
Benefit Plan reimbursements,
0. (If Applicable) — if a Flex Plan participant uses his/her Flex benefits card fora transaction that falls outside of the benefits card
parameters set forth by the IRS, a request for substantiation will be sent automatically via e-mail. If no response is received
within 14 days a second electronic letter will be sent. If no response is received within 7 days, the benefits card will be
deactivated and the expense deemed ineligible.
Once a card is deactivated, the participant will no longer have the ability to use their card until he/she provides resolution
through one of the following methods:
Provide receipts as substantiation to Igoe Administrative Services along with a copy of the letter he/she received. The
information may be faxed to 858-777-5424. Upon receipt, the transaction will be approved therefore reactivating the
benefits card.
• Refund the Flexible Benefit Plan equal to the amount of the transaction via either a payroll deduction or a personal
check. Upon notification from the employer that the refund is complete, the transaction will be reversed therefore
reactivating the benefits card.
• The employer may add the amount of the ineligible transaction to the employee's W-2 as taxable income. Upon
notification from the employer that this action is being taken, the transaction will be approved therefore reactivating the
benefits card.
Obligations of Covered Entity in accordance with HIPAA regulations regarding Protected Health Information (PHI):
A. Covered Entity shall notify Business Associate of any restriction to the use or disclosure of Protected Health Information that
Covered Entity has agreed to in accordance with 45 CFR 164.522, to the extent that such restriction may affect Business
Associate's use or disclosure of Protected Health Information.
B. Covered Entity shall not request Business Associate to use or disclose Protected Health Information in any manner that would
not be permissible under the Privacy Rule if done by Covered Entity.
Plan Administrator/Plan Sponsor acknowledges that they have read;this Agreement in its entirety and Plan AdministratoriPlan Sponsor
acknowledges that It has been advised to consult with, and has consulted as it deems necessary, its own attomey with respect to the
,lGt�,E
9/24/2008 ACIMINI5TRATIVE SERVICES
matters herein, and acknowledges that Contract Administrative Firm is not providing any tax or legal advice as a result of its professional
services under this Agreement. In addition, the Plan Administrator/Plan Sponsor agrees to the fees outlined in Exhibit A and Exhibit B of
this Agreement. Failure to pay fees when due may result in termination of this Agreement. The Administrative Fee Schedule, which is
attached to this Agreement as Exhibit A, is made a part hereof as of the effective date of this Agreement.
7. Should either party institute legal action to enforce its rights under this Agreement, the venue shall be in San Diego County, State of
California, and the prevailing party in such action shall be entitled to recover reasonable attorney's fees and costs.
8. Should Plan Administrator/Plan Sponsor, at any time during the coverage period of this Agreement, file in the United States for the Debt
Relief or Reorganization of any type, all services from the date of the filing forward shall be terminated immediately.
9. Plan AdministratorlPlan Sponsor agrees to accurately complete an administrative instruction/summary form, as supplied by the Contract
Administrative Firm, upon implementation or renewal of the Plan. Plan Administrator/Plan Sponsor agrees that these forms will provide
the basis of the Contract Administrative Fin's administrative actions under this Agreement. Further, Plan Administrator/Plan Sponsor
agrees that any changes to the infonnatlon supplied on these forms may only be made in writing and are only effective when
acknowledged by the Contract Administrative Firm in writing. Additional fees may be incurred for any retroactive changes made aver
the Plan Administrator/Plan Sponsor has agreed to the administration design in writing or for any changes which may be requested mid-
year (after the open enrollment period).
10. Term and Termination.
A. Term, This Agreement shall govem the contract period beginning January 1, 2009 and ending December 31, 2009, unless
terminated earlier by either party at any given time upon thirty (30) days written notice.
B. The Term of this Agreement shall be effective as of the date of the signature on this Agreement, and, with respect to HIPAA
Privacy Rules, this Agreement shall terminate when all of the Protected Health Information provided by Covered Enfity to
Business Associate, or created or received by Business Associate on behalf of Covered Entity, Is destroyed or returned to
Covered Entity, or, If it is infeasible to return or destroy Protected Health Information, protections are extended to such
information, in accordance with the termination provisions in this Section.
C. Termination for Cause. With respect to HIPAA Privacy Rules, upon Covered Entity's knowledge of a material breach by
Business Associate, Covered Entity shall provide an opportunity far Business Associate to cure the breach or end the violation
and terminate this Agreement and the Administrafive Services Agreement if Business Associate does not cure the breach or
and the violation within the time specified by Covered Enfity, or immediately terminate this Agreement and the Administrative
Services Agreement sections if Business Associate has breached a material term of this Agreement and cure is not possible.
D. Effect of Termination.
i. Except as provided for above with respect to HIPAA Privacy Rules, upon termination of this Agreement, for any
reason, Business Associate shall return or destroy all Protected Health Information received from Covered Entity, or
created or received by Business Associate on behalf of Covered Entity. This provision shall apply to Protected
Health Information that is in the possession of subcontractors or agents of Business Associate. Business Associate
shall retain no copies of the Protected Health Information.
ii. In the event that Business Associate determines that returning or destroying the Protected Health Information is
infeasible, Business Associate shall provide to Covered Entity notification of the conditions that make return or
destruction infeasible. Upon mutual agreement of the Parties that return or destruction of Protected Health
Information is infeasible, Business Associate shall extend the protections of this Agreement to such Protected Health
Information and limit further uses and disclosures of such Protected Health Information to those purposes that make
the return or destruction infeasible, for so long as Business Associate maintains such Protected Health Information.
11. Miscellaneous.
A. Applicable Law. This Agreement shall bg governed by and construed in accordance with the laws of the State of California.
B. Assi-griabillity. This Agreement and the rights, benefits, privileges, dufies and responsibilities of the parties hereto may not be
assigned by any other party hereto without the prior written consent of the parties hereto.
C1GOE
912412008 ALIMINISTRAIIVE SERVIEES
C. Amendment: In regard to Protected Health Information (PHI), the Parties agree to take such action as is necessary to amend
this Agreement from time to time as is necessary for Covered Entity to comply with the requirements of the Privacy Rule and
the Health Insurance Portability and Accountability Act, Public Law 104-191.
D. Binding Nature of Agreement. This Agreement is binding upon signature by both parties and shall inure to the benefit of the
heirs, executors, successors and assignors of the parties hereto.
E. Complete Agreement. This Agreement and all accompanying Exhibits constitute the complete Agreement of the parties
regarding its subject matter and replaces and supersedes any prior written or oral agreement between the parties regarding its
subject matter.
F. Confidentiality. The Contract Administrative Firm will maintain the confidentiality of all records and information obtained in
conjunction with the services to be performed hereunder in accordance with HIPAA Privacy regulations. The information
therein shall not be divulged or disclosed or made available to persons, other than the Plan Sponsor/Plan Administrator,
without written approval by the Plan Sponsor/Plan Administrator or a court of competent jurisdiction. This paragraph will
survive the termination or expiration of the Agreement.
G. Construction and Severability. The captions of this Agreement and its paragraphs and subparagraphs are for the convenience
of the parties only and shall not be taken in account in the construction and interpretation of this Agreement. The terms of this
Agreement are severable; should any portion of this Agreement be invalid or unenforceable, such Invalidity or unenforceability
shall not affect the validity or enforceability of the remainder of this Agreement and this Agreement shall be construed and
interpreted as though such invalid or unenforceable provision was not contained herein.
H. Independent Contractor. The Contract Administrative Firm's relationship with Plan Administrator/Plan Sponsor is that of
Independent. contractor and nothing in this Agreement shall be construed as creating the relationship of employer or employee
between the Plan Administrator/Plan Sponsor and officers, employees, or agents of the Contract Administrative Firm or the
relationship of a partnership or joint venture between the parties, as outlined in Section 4 of this Agreement.
I. Interpretation. In regard to Protected Health Information (PHI), any ambiguity in this Agreement shall be resolved in favor of a
meaning that permits Covered Entity to comply with the Privacy Rule..
J. Modifications. This Agreement may not be modified or amended except by means of written modification or amendment of
this Agreement or their legal successors in interest.
K. Regulatory References. All references in this Agreement to a section in the Privacy Rule means the section as in effect or as
amended, and for which compliance is required under the Health Insurance Portability and Accountability Act, Public Law 104-
191.
L. Survival The respective rights and obligations of Business Associate under HIPAA Privacy Rules, as outlined in this
Agreement, shall survive the termination or expiration of this Agreement.
M. Warranties. No representations or warranties have been provided by any party to this Agreement or to any other party to this
Agreement exceptas specifically set forth in this Agreement.
12. Indemnification of the Contract Administrative Firm ("Business Associate} and the Plan Administrator/Man Sponsor l"Covered Entity"
Contract Administrative FirmlBusiness Associate shall Indemnify, defend and hold harmless Plan Administrator/Plan Sponsor, its
affiliates, directors, officers and employees or any of them from any claim, expense, loss, damage, settlement, judgment, penalty and
liability, including reasonable attorneys' fees and court costs (individually and collectively, "Claims") resulting in any way from or arising
out of Contract Administrative Firm's/Business Associate's performance of or failure to perform this Agreement, including, without
limitation, Claims resulting from or arising out of acts or omissions by Contract Administrative Firm/Business Associate, its employees,
officers, directors, agents, or other individuals who provide services under this Agreement.
Plan Administrator/Plan Sponsor shall indemnify, defend and hold harmless Contract Administrative Firm/Business Associate, its
affiliates directors, officers and employees or any of them from any claim, expense, loss, damage, settlement, judgment penalty and
liability including reasonable attorneys fees and court costs (individually and collectively, "Claims") resulting in any way from or arising
out of Plan Administratoes/Plan Sponsor's performance of or failure to perform this Agreement, including, without limitation, Claims
resulting from or arising out of acts or omissions by Plan Administrator/Plan Sponsor, its employees officers, directors, or agents.
CIGOE
912412008 AUMINis,rNAIIVE SERVICES
The Parties to the agreement consent and agree to all of the provisions and by their signature cause this Agreement to
become effective as of the date of signature. Remittance of and acceptance of payment for services hereby binds both parties
to this agreement.
By:
City of Vernon Amended and Restated Flexible Benefit Plan
('Covered Entity")
By:
Date:
Plan Sponsor/Plan Administrator:
City of Vernon
By:
Date:
Contract Administrative Firm
("Business Associate")
Date: September 24, 2008
I IE
9/24/2008 AUMINISMA"FIVE SERVICES
EXHIBIT A: ADMINISTRATIVE FEE SCHEDULE
City of Vernon
RATES EFFECTIVE JANUARY 1, 2009
MONTHLY ADMINISTRATIVE CHARGES — Flexible Spending Accounts
Monthly Administration Fee: $200.00
ADMINISTRATIVE SERVICES INCLUDED IN ABOVE FEE
The following services are included in the monthly administration fee
Actual Postage Expenses _
INCLUDED
Multiple Payroll Cycles
INCLUDED
For example: weekly & bi weekly, monthly & weekly, etc.
Plan Year End Run Out Period Processing
INCLUDED
Igoe Administrative Services will process Run Out Period reimbursement submittals on a set administrative
"ALL ACTIVE PARTICIPANTS WITH POSITIVE BALANCES
schedule
DURING THE PLAN YEAR RUN OUT PERIOD WILL BE
CHARGED ACCORDING TO THE ABOVE FEE SCHEDULE
2.5 Month Grace Period Processing (E)tension Period)
INCLUDED
Igoe Administrative Services will process the up to 2.5 Month Grace Period (fomrerly known as the Extension
'"ALL ACTIVE PARTICIPANTS WITH POSITIVE BALANCES
Period) reimbursement submittals on a set administrative schedule.
DURING THE 2.5 MONTH GRACE PERIOD WILL BE
CHARGED ACCORDING TO THE ABOVE FEE SCHEDULE
Electronic Enrollment Confirmation
INCLUDED
Igoe Administrative Services will send an enrollment confirmation at the start of the plan year to all plan
participants that provide an e-mail address.
Electronic Plan Year End Reminder Notification
INCLUDED
Igoe Administrative Services will send a reminder notification including run out deadlines to all plan.
participants that provide an e-mail address.
Non -Discrimination Re -Testing (125 Plans)
INCLUDED
Applies when retesting Is required due to client not providing requested data at Open Enrollment, or anytime
during the year when the client requests the Plos) to be retested
Flex Benefits Card Reactivation (if applicable)
INCLUDED
A Flex Benefits Card may become de -activated if an employee does not comply with Flex Benefits Card
requirements
Flex Benefits Card Replacement (if applicable)
INCLUDED
Applies when a Flex Benefits Card is lost or stolen & client requests replacement card
"If plan pattidpation ctranges by 100/6 or more during this contract ptelod, Igoe Administrative Services reserves the tight to adjust the rnonthy
aftwsmft fee by the exact percentage of the parrt opafion change.
ANNUAL RE -ENROLLMENT FEE
Provided Igoe Administrative Services and the client mutually accept future services, Igoe Administrative Services reserves the right to charge an
Annual Enrollment Fee. The client will be provided with a proposal of tees for the new Plan Year no faW than 60 days before the end of the
current Plan Year. All fees for services must be paid in full prior to the preparation of any renewal materials. Included services are:
♦ Load -on of all new enrollments and txlilding of new database for each Plan Year
♦ Add newparGcipants afteriniticl setup of Plan
Preparation of new master enrollment materials
The minimum nvft fee WN apply when a cckent chooses not to renew for the next Wan Year and requests Igoe Admkg tratAm Services to
administer the Plan Year Run Out Period for the ending Plan Year.
ARLIE
912412W8 ALMINIS HAIML 5I NVIIx5
OPTIONAL ADMINISTRATIVE FEES
The following services are not included in the administration fees. The client will incur additional fees when these
services are required or requested.
Any services not explicitly outlined in this Agreement may require additional fees. Optional services may include, but are not limited to, Specialized
Reporting, Additional Services, Information Systems Programming or Consultation. Fees for these services will be determined based on the time
required to complete said service and will be agreed to by both parties prior to performance of such services.
Special Check Run
$25.00
Checks produced on non-scheduled processing day -Additional fees will apply when client requests
PER SPECIAL RUN
replacement check/s be generated prior to next scheduled processing day
Flex Benefits Card Set -Up
$100.00
If client implements the Flex Benefits Card
Flex Plan Document Amendments/Restatements
$150.00
Applies when a Plan Document Amendment is necessary to keep your Plan in compliance
WebEx
ADDITIONAL FEES MAY APPLY, PLEASE
Professionally trained Igoe staff members are available by appointment to conduct a live, interactive
CONTACT YOUR ACCOUNT MANAGEMENT
enrollmenticlient education/ or participant education meeting via the internet, The length of the call and the
TEAM TO OBTAIN A QUOTE
number of connections included determine the fees for this service.
ItOE
912412008 AUMINISTHATIVE SERV1EES
EXHIBIT B: ADMINISTRATIVE SERVICES
ON -GOING ADMINISTRATIVE SERVICES
The following services are included in the administration fees.
0
'view Online Employer Access To Documents and Reports
The WRO site allows you to view all customized forms, reports and documentation regarding your Flex Plan. Access
to this site will be restricted by 128-bit encrypted super -certificate from Thawte to ensure the strongest possible online
security. Your Account Management Team will provide a demonstration of this site upon implementation.
24-Hour On -Line Participant Account Information
Participants are given online access with abilities to check account balance and transaction information via the Igoe
Administrative Services web site at www.goigoe.com. Upon enrollment for each new Plan year, all website login
information will be provided to you for distribution.
Participant Services
Igoe Administrative Services Participant Services Department is comprised of a team of qualified personnel available to
assist Participants by answering questions and resolving issues that may arise during the Open Enrollment Period and
throughout the Plan Year. The Participant Services Team is trained to respond to Participant issues such as; account
balance inquiries; contributions, reimbursements, requests posted to Participant accounts; questions on denied requests
for which a Participant has received a letter; education regarding eligibility of expenses; confirmation of processing
deadlines or reimbursement methods; and IRS Guidelines and Section 125 regulations.
Annual Non-discrimination Testing (When Required for 125 Plans)
Non-discrimination Testing will begin upon receipt of participant Enrollment Forms, elections and required IRS Non-
discrimination information. Three separate tests will be conducted following each Open. Enrollment Period to ensure that
your Plan is in compliance with IRS Non-discrimination requirements, as follows:
♦ 250/6 Concentration Test: Testing is required to confirm that no more than 25% of the total benefit is
contributed by key employees.
♦ 55% Average Benefit Test; Testing is required to confirm that more than 55% of the average DCAP benefit
is contributed by non -highly compensated employees.
♦ 50/9 Owner Benefits Test: Testing is required to confirm that no more than 25% of the total DCAP benefit is
contributed by 5% owners of the firm.
Standard Reporting Services
♦ Provide reimbursement register or reimbursement report to coincide with processing schedule
♦ Provide monthly management report
♦ Provide annual IRS Form 5500 Reporting, if applicable
('hGOE
912412008 AUMINISINATIVE 5ERVICE5
Ongoing Education
Through the Igoe Administrative Services web site: www.goiooe.com, Administrators, Participants and those interested
may access:
♦ Rules and Regulations governing IRS Section 125 Flexible Benefit Plans
♦ Updated publications provided by the Internal Revenue Services (IRS)
♦ Links to the Internal Revenue Service (IRS)
♦ Frequently asked Questions with Answers
in addition, the viewer may download, free of charge:
♦ Medical Care Reimbursement Plan Worksheets
♦ Dependent Care Assistance Plan Worksheets
♦ Medical Reimbursement Plan Request Forms
♦ Dependent Care Assistance Plan Request Forms
♦ Dependent Care vs. Tax Credit Worksheet
♦ Sample Childcare Provider Receipt
Enrollment Materials
A Master set of Enrollment Materials are created by Igoe Administrative Services prior to each Open Enrollment Period
and forwarded to your firm via e-mail at no charge.
1G�F
912412000 ADMINISTRATIVE SERVICES
EXHIBIT C: FUNDING REQUIREMENTS
FUNDING OPTION 1— PAYROLL, REIMBURSEMENT:
The Plan Sponsor/Plan Administrator will maintain all FSA related funds. Igoe Administrative Services will provide
notification directly to the Plan Sponsor/Plan Administrator of all reimbursements to be included on the Plan Sponsor/Plan
Administrator's next scheduled pay date.
FUNDING OPTION 2 — MANUAL REIMBURSEMENT FROM PLAN SPONSOR ACCOUNT:
The Plan Administrator/Plan Sponsor shall establish a zero -balance Flexible Benefit Plan checking account and authorize
Michael C. Igoe as a signer. If Plan Administrator/Plan Sponsor does not want to add Michael C, Igoe as a signer on said
account, unsigned checks will be provided directly to the Plan Administrator/Plan, Sponsor for signature and dispersment.
FUNDING OPTION 3 — MANUAL REIMBURSEMENT/DIRECT DEPOSIT FROM IGOE ACCOUNT:
Igoe Administrative Services will issue physical checks to Plan participants on behalf of the Plan Sponsor/Plan
Administrator. Reimbursement checks will be issued using Igoe Administrative Services contracted bank. The Plan
Sponsor/Plan Administrative will have a unique routing/account number to ensure that all plan related funds are held in
sole and separate accounts. The Plan Sponsor/Plan Administrator will prefund said account with one month's worth of
salary redirections (minimum of $5000.00 required) and agrees to replenish all funds used for Plan reimbursement within
2 business days of the check issuance date. Igoe Administrative Services reserves the right to suspend the delivery of
participant reimbursements. if said account is not funded as required on the scheduled processing date.
Igoe Administrative Services will handle all banking related services such as but not limited to, stop payments, reissuance
of checks, research of stale dated checks, monthly account reconciliation.
FUNDING OPTION 4 — BENEFITS CARD:
Plan Sponsor/Plan Administrator will provide ACH abilities to Metavante/Medibank for the funding of benefit card
transactions only. This option can be paired with either of the above for non -benefits card transactions.
Clh�OE
912412008 AUMINISINATIVE SE13VICES
ADMlNNTHAME SERVICES
Wire Transfer Information
(Payment of Administrative Fees and/or Replenishment of Igoe Banking Account)
Please Type or Print Clearly
Client Name (party initiating wire transfer): cITY OF VMQ1
Taxpayer Identification Number (TIN): 95-6000808
Company Contact Name for Remittance Only: MAMA Luxe
Company Contact Telephone Number: (323) 583=8811 M. 200
Company Contact e-mail Address: cluna@ci.vernon.ea.us
Company Fax Number: (323) 826-1491
Igoe Administrative Services. Wire Transfer Information
Bank: California Bank and Trust
Bank Address: 11717 Bernardo Plaza Court, San Diego, CA 92128
Account Name: Igoe & Company, Incorporated
Routing Number: 122232109
Account Number: 21-101645-01
By signing this agreement, the above named client agrees to make payments
and/or replenish their Igoe maintained bank account within the time frame
outlined in the current Administrative Service Agreement. Client agrees to
email accountin_p_ooigoe.com_whenever a wire transfer is initiated confirming
the amount of the transfer and the purpose of the wire transfer. If the transfer
is meant to pay for administrative services, the invoice number must be
provided in the email notification. Furthermore client agrees to treat the above
information as confidential.
SHARQN DUCKWORTH
Authorized Contact (Please print)
Authorized Signature
CITY XUMMM
Job Title
�dxgloQ
Gate
Please email this form to:
Igoe Administrative Services Accounting Department at .accounting ftoigoe.com.
If email is not an option, the farm may be faxed to (898) 68240M
i
ALIMINISTRATIVE SERVICES
FSA ENROLLMENT DATA FEED PROGRAM
DataFeed Overview...............................................................
The new data feed system was developed with flexibility and security in mind; allowing you to easily create and transmit
your file over a secure connection. Data Feeds are simply a file or files that contain the information from your system
necessary to enroll your employees in one or more Flexible Spending Account Plans in our system.
Data Feeds should only consist of employees that are enrolling in at least one FSA plan. Your data should be sent using
two distinctly different record types:: Igoe Administrative. Services prefers that all files combine each record type in a
1,2,1,2 sequence. The first record type, called the Employee Record, will contain your employee's general information
such as the Social Security Number, name, and address. The second file, called the Elections Record, will include
enrollment information such as plan type, annual election, and per pay period election. The Elections Record should be
repeated for each benefit type being elected.
IMPORTANT NOTE: OPEN ENROLLMENT FILES SHOULD CONTAIN ALL RECORDS INDICATING A POSITIVE FSA ELECTION. FILES
USED FOR ONGOING ELIGIBILITY TRANSFERS CAN ONLY CONTAIN CHANGE ONLY RECORDS (EX: NEW ELECTIONSINEW HIRES,
TERMINATIONS, CHANGE IN STATUS/QUALIFYING EVENTS, AND DEMOGRAPHIC CHANGES). IGOE ADMINISTRATIVE SERVICES DOES
NOT ACCEPT FULL FILES OUTSIDE OF OPEN ENROLLMENT.
Record1: Employee Record.....................................................................
The Employee Record Will consist of one row for each employee that will be enrolling in at least one FSA plan.
Note (Required fields are bold)
Field
Data '
;Max
Formats ?
Description =
Name'
T e. ;
Len' h,
SSN
Text
11
999999999 or 999-W
9999
Last Name
Text
20
First Name
Text
20
MI
Text
1
Middle Initial
Address
Text
30
Address2
Text
30
Use Address2 9 your Address
field exceeds the 30 character
limit.
city
Text
25
State
Text
2
AZ, CA etc...
Any valid State code
Zip Code
Text
10
99099, 999999999 or
99999-9%9
Hire Date
Date
mrh/dd/yyyy or
mni/ddtyy.
Play Mode
Text
2
Values (A B,S,M�W,)
Payroll frequency
Your code could vary
A=Annual I=Biweekly
depending on your
S=Semimonthly M:*Monthty
Payroll frequencies
WoWeekl ,
Status -
Text
1
A x Active
('i'-DE
Mi
912412008 AUMINISTNATIVE SENVICES
T = Termed
L = Leave of Absence
R = Return from Leave of
Absence*
C = Change in
status/demographic, than a**
Term Date
Date
10
mm/dd/yyyy or
The date that the employee
mm/dd/yy
termed either employment of
all benefits associated with
their record
First phone
Text
14
9999999999, 999-999-
#
9999 or (999) 999-
9999
Second
Test
14
9999999999, 999-999-
Phone #
9999 or (999) 999-
_
9999
Email
Text
30
userO-host.com
This field is required if you
Address
are offering FSA debit cards
to our clients . _
First Pay
Date
10
mm/dd/yyyy or
The first pay day their
Date
mm/dd/yy
deductions will take place
Effective.
Location
Text
2
Required if locations are
Code
tracked by Igoe
Division
Text
2
Required if divisions are
Code
tracked b Igoe
Department
Text
5
Required if departments are
Code
tracked by Igoe
Officer &
Text
1
Values (Y or N)
Y" if employee is an officer and
Over 150K
earns more than $130K; "N" if
th " are not.
1% owner
Text
1
Values (Y or N)
"Y" if employee is at least a 1%
& over
owner and earns over $150K;
$150K
"N" if th " are not
Over 5%
Text
1
Values (Y or N)
"Y" if employee is over 5%
owner
owner; "N" if they are not
Earns
Text
1
Values (H or N)
If employee is highly
105K
compensated use "H"; "N" if
they are not
*CAUTION —WHEN USING THE "R" STATUS, PLEASE ENSURE THAT ALL PREVIOUSLY MADE CONTRIBUTIONS ARE TAKEN INTO
CONSIDERATION WHEN CALCULATING THE PER PAY PERIOD INFORMATION ON THE ELECTIONS RECORD
**CAUTION — WHEN USING THE "C" STATUS FOR A QUALIFYING EVENT, PLEASE ENSURE THAT THE ACTUAL EFFECTIVE DATE
LISTED ON THE ELECTIONS RECORD INDICATES THE EFFECTIVE DATE OF THE STATUS CHANGE, NOT THE DATE THE CHANGE WAS
ENTERED OR THE ORIGINAL ELECTION EFFECTIVE DATE.
912412008 ALIMIN151HAIIV SEHVILE5
Record 2: Elections Record........................................................... .....
The Elections Record will be associated to the Employee Record using the SSN. This means an employee must exist
on the Employee Record with the same SSN or the corresponding election(s) will not be added. If you have multiple
plans with Igoe Administrative Services then you could potentially have more than one election record for each
employee. An example of this would be if you had Medical and Dependent Care plans. To enroll an employee in both
plans they would have two rows providing election information for each plan.
Note (Required fields are bold)
;Field Name ,.
Da>fa Type=
__ r
Ma>S Length
Formats
D61criptian
SSN
Text
11
999999999 or 999-99-
This is used to link to
9999
an employee in the
Employee File. An
Employee must exist
in the Employee File
with this SSN or it
will not be added. -
Plan Type
Text
1
Values (1 or 2)
1=Dependent Care 2
Medical Care
Annual
Number
11
9999.99 or 9,999.99
Annual Election
Election
Pay Period
Number
11
9999.99 or 9,999.99
Amount deducted for
Deduction
each pay period.
Effective Date
Date
10
mmldd/yyyy or mm/dd/yy
For Open
Enrollment = Date
new plan year will
start.
For new
hires/election
changes* = Date the
election is effective
from a regulatory
standpoint
*CAUTION —WHEN USING THE "R" STATUS, PLEASE ENSURE THAT ALL PREVIOUSLY MADE CONTRIBUTIONS ARE TAKEN INTO
CONSIDERATION WHEN CALCULATING THE PER PAY PERIOD ON THE ELECTIONS RECORD. WHEN USING THE "C" STATUS FOR A
QUALIFYING EVENT, PLEASE ENSURE THAT THE ACTUAL EFFECTIVE DATE LISTED ON THE ELECTIONS RECORD INDICATES THE
EFFECTIVE DATE OF THE STATUS CHANGE, NOT THE DATE THE CHANGE WAS ENTERED OR THE ORIGINAL ELECTION EFFECTIVE
DATE.
4GOE
912412008 AUMINNIHATIVE SEHVILE5
PAY PERIOD
PAYDATE
1.
12/07/08 -
12/20/08
0� /01 ro9
2.
12/21 /08 -
01 /03/09
3.
01/04/09 -
01 /17/09
01 /29109
4.
01 /18/09 -
01 /31 /09
02/12/09
5.
02/01 /09 -
02/14/09
02/26/09
6.
02/15/09 -
02/28/09
03/12/09
7.
03/01 /09 -
03/14/09
03/26/09
8.
03/15/09 -
03/28/09
04/09/09
9.
03/29/09 -
04/11/09
04/23/09
10.
04/12/09 -
04/25/09
05/07/09
11.
04/26/09 -
05/09/09
05/21 /09
12.
05/10/09 -
05/23/09
06/04/09
13.
05/24/09 -
06/06/09
06/18/09
14.
06/07/09 -
06/20/09
07/02/09
15.
06/21/09 -
07/04/09
07/16I09,
16.
07/05/09 -
07/18/09
0130/OJ
17.
07/19/09 -
08/01/09
08/13/09
18.
08/02/09 -
08/15/09
08/27/09
19.
08/16/09 -
08/29/09
09/10/09
20.
08/30/09 -
09/12/09
09/24/09
21.
09/13/09 -
09/26/09
10/08/09
22.
09/27/09 -
10/10/09
10/22/09
23.
10/11/09 -
10/24/09
11/05/09
24.
10/26/09 -
11 /07/09
11 /19109
25.
11 /08/09 -
11 /21 /09
12/0316
26.
11 /22/09 -
12/05/09
12/17/09
27.
12/06/09 -
12/19/09
Tax 113.95-3391660
DATE; November 18, 2008
REFERENCE # November 18, 2008
FOR; City of Vernon 2009 Renewal
Katina Rueda
City of Vernon
4305 Santa Fe Ave
Vernon, CA 90058
Benefit Plan Renewal
300.00
**PAYMENT MUST BE RECEIVED IN FULL BEFORE IGOE WILL
BEGIN IMPLEMENTATION**
Renewal fees will be taken via ACH
If you have any questions concerning this invoice, please contact:
Your Account Management Team at flexsupport@goigoc.com
TOTAL
THANK YOU FOR YOUR CONTINUED BUSINESS!
4305 Santa Fe Avenue, Vernon, California 90058
Telephone (323) 583-8811
December 11, 2008
IGOE & Company, Inc.
Attn: Michael C. Igoe
President & CEO
16769 Bernardo Center Drive, Suite 21
San Diego, CA 92128-2548
Re: Flexible Benefit Plan Administrative Services Agreement
Dear Mr. Igoe:
Transmitted herewith is a copy of the fully executed agreement as
referenced above, approved by City Council on November 24, 2008,
through Resolution No. 9771.
If you have any questions regarding this matter, please call Mr.
Willard Yamaguchi, at (323) 583-8811 ext. 175.
..V ry truly yours,
ell Gii
City Clerk
NG:dr
c: Willard Yamaguchi
Purchasing Department
Resolution No. 9771
Agreement No. 08-114
Evc(usivefy Industrial
Aff
ff Uw"&
AUMIN115TRATIVE SERVIEE5
November 25, 2008
Ms. Karma Rueda
City of Vernon
4305 Santa Fe Ave.
Vernon, CA 90058
RE: FLEXIBLE BENEFIT PLAN ADMINISTRATIVE SERVICES AGREEMENT/RENEWAL
Dear Ms. Rueda:
Igoe Administrative Services is excited to offer another year of administration on your current Flex account! Outlined on the
following pages is a summary of your current plan design and administration, as well as a new Administrative Services
Agreement for your review. Please review this information carefully to ensure that everything is correct. If you wish to make any
plan design/administrative changes, please indicate such in all appropriate sections. Once this information is received a new
Administrative Services Agreement will be forwarded to you.
The following items are required in order to complete the renewal process:
1. A fully executed copy of the Administrative Services Agreement (ASA). By signing the attached ASA, please note that
you are also affirming all plan design/administrative information included in your renewal packet. Please do not sign
the attached ASA if you wish to make any changes to your plan design or administration.
2. A list of all pay dates that will have a salary redirection during the upcoming plan year.
Upon receipt of all items listed above, your Igoe Account Management Team will forward you new enrollment materials and
contact you to coordinate the timing of your new enrollments. Please keep in mind that it may take up to 10 business days for
Igoe to process the attached paperwork.
We would appreciate the opportunity to discuss your plan year renewal. Your Account Management Team will be contacting you
shortly to make recommendations on service options that may benefit your current administration.
We thank you for your continued business and look forward to another year of partnership.
Sincerely,
Michael C. Igoe
President & CEO
Enclosures
cc: Brenda Lee (Gallagher Benefit Services, Inc.)
P.O. Box 501480 San Diego, CA 92150-1480
858-673-3670 800-633-8818 Fax No. 858-673-3666 888-357-6307 www..qo4goe.com
"IGOE
AD10/ INISTRATtVE SERVICES
CLIENT VERIFICATION
Please review the current data for your Flex Plan. This will update your client records, enrollment materials, and Plan Documents
keeping your Plan in compliance. Please make changes directly on this form, sign and return to your Account Management Team at
flexsupport(cDgoiaoe.com or via fax at fax: (858) 777-5424.
Section I: Demographic Information*
Client: City of Vernon
4305 Santa Fe Ave.
Vernon, CA 90058
(323) 583-8811
Main Hit Contact:
Telephone:
E-mail:
Broker Name:
Broker Co:
Telephone:
E-mail:
Entity type:
[ ] C Corporation
[ l LLC
[� Government agency
Karina Rueda
(323) 583-8811 x325
krueda@ci.vernon.ca.us
Brenda Lee
Gallagher Benefit Services, Inc.
(818) 539-1321
brenda_lee@ajg.com
[ ] S Corporation [ ] Non profit [ ] Partnership
[ ] LLP [ ] Sole Proprietorship [ ] Union
Please indicate if you are a member of an affiliated service group: V.] No [ ] Yes - If "Yes", list all other members of the group:
Please indicate if you are a member of a controlled group: $ ] No [ ] Yes - If "Yes", list all other members of the group:
*Changes to this section will not prompt a revision of the attached ASA.
Section II: Plan Review
Plan Year:
January 1, 2009 - December 31, 2009
2.5 Month Grace Period:
NIA
Plan Year Run -Out End:
the last day of February following the close of the Plan Year
Termination Run -Out End:
60 days following the date of termination
Eligibility to Participate:
the first day of the month following coincident or following the date of hire
Classification:
classified as a full-time employee
Minimum Eligible Hours:
NIA
Dependent Annual Maximum:
Medical Annual Maximum:
Limited Purpose FSA wligoe:
Other Insurance Premium Plan
Transit I Parking Plan:
Fiscal Year End pate:
$5,000 ($2,500 married filing separately)
$5,000
NO
NO
NO/NO
June 30
NOTE: ANY CHANGES TO PLAN DESIGN WILL REQUIRE AN AMENDED & RESTATED PLAN DOCUMENT AT A FEE OF $150.00. ADDITIONALLY, ANY CHANGES
MADE TO THIS SECTION MAY PROMPT A REVISION TO THE ATTACHED ASA.
(Aqji"�F
1112512008 AUMIMSIRAT'IVE SERVICES
Section III: Administration
Total # of Pay Periods: 27
Paydays: Every Other Thursday
Reimbursement Processing Method: MICR Checks
Reimbursement Processing Cycle: Every Other Thursday (same as payday)
PLEASE PROVIDE A LIST OF ALL PAY DATES THAT WILL HAVE A SALARY REDIRECTION DURING THE UPCOMING PLAN YEAR. THIS LIST IS REQUIRED IN ORDER
TO COMPLETE THE RENEWAL PROCESS.
CHANGES MADE TO THIS SECTION MAY PROMPT A REVISION TO THE ATTACHED ASA.
Section IV: Enrollment Verification
Total number of benefit eligible employees: 300
If the above number is incorrect or has changed, please provide the total number of benefit eligible employees as of this notice:
Will open enrollment information be communicated from an outside vendor? [ ] No DC] Yes — list vendor name and contact information
GALLAGHER BENEFIT SERVICES, INC-, ATTN: AT.T.YN R. IIEC i; (e.g. BeneTrac, ADP, etc) **
505 NORTH BRAND AVENUE BLVD., SUITE 600, GLENDALE, CA 91203-3944
Will mid year enrollments & changes be communicated from an outside vendor? W No [ ] Yes — list vendor name and contact
information (e.g. BeneTrac, ADP, etc) "*
**IF OPEN ENROLLMENTIONGOING FILES WERE NOT PREVIOUSLY APPROVED BY IGOE ADMINISTRATIVE SERVICES, PLEASE FORWARD THE INCLUDED FILE
SPECIFICATIONS TO YOUR VENDOR. ALL FILE TRANSFERS MUST CONFORM TO THE ATTACHED SPECIFICATIONS UNLESS EXPRESSLY AGREED TO IN WRITING BY
ALL PARTIES.
Section V: Authorization
Your signature below is:
❑ Confirmation that all above information is correct or that the appropriate changes have been noted above. (Write
corrections directly on the form before returning. Written information will be acted upon. If such documentation,
requires a change to the included ASA or an addition to your renewal fees, a revised ASA and renewal invoice Will be
provided) - Please sign the attached ASA if no changes were made to the above information.
❑ Acknowledgement that Igoe Administrative Services is NOT responsible for missing or incorrect information not noted
above.
❑ Acceptance of the 2009 Plan Year Re -enrollment Fee of $300.00.
❑ Agreement that you understand that additional fees apply when:
• Plan changes and/or corrections that affect the materials are reported after materials have been created for the new Plan
Year -including mid -year changes.
• Non -Discrimination changes and/or corrections that affect testing results are reported after tests have been run.
• Administrative or Plan Design changes are made - including mid -year changes.
Client Signature Date
1112512008 ADMINISTRAINE SERVICES
AGUE
ADMINISTRATIVE IVE SERVICES
CITY OF VERNON FLEXIBLE BENEFIT PLAN
ADMINISTRATIVE SERVICES AGREEMENT
This Agreement specifies the services to be provided to City of Vernon, in the ongoing administration of the City of Vernon Amended and
Restated Flexible Benefit Plan (the "Plan"I"Covered Entity") as well as the specified responsibilities of City of Vernon (the, "Plan
Administratoff'Plan Sponsor") and Igoe Administrative Services (the "Contract Administrative Firm"/"Business Associate"). The Contract
Administrative Firm ("Business Associate") shall be engaged by the Plan Administrator/Plan Sponsor as a subcontractor in the performance of
administrative services for the Plan.
1. In accordance with the terms of this Agreement, the Contract Administrative Firm shall have the following responsibilities:
A. The Contract Administrative Firm shall provide Flexible Benefit Plan services in accordance with this Agreement, as requested
by the Plan Administrator/Plan Sponsor in connection with the Plan.
B. The Contract Administrative Firm shall consult with Plan Administrator/Plan Sponsor on the design of the Plan.
C. The Contract Administrative Firm shall provide the Plan Administrator/Plan Sponsor with the following sample documentation
in order to initiate the administrative function:
(i) A sample Plan Document for review and potential adoption by Plan Sponsor and Plan Sponsor's legal counsel;
(ii) A master set of Employee Communication/Enrollment Materials, including:
a. A Summary Plan Description; and
b. Election Forms to be used during the Enrollment Process; and
C. Reimbursement Request Forms; and
d. Instructions for filing claims for reimbursement and appeals procedures.
The Plan Sponsor is not required to adopt or utilize the sample Plan Documents, Enrollment Materials or Forms provided by
the Contract Administrative Firm and may use its own forms, subject to review by the Contract Administrative Firm. Contract
Administrative Firm makes no warranties or representations regarding the adequacy of such documentation. Additional fees
may apply if additional work is required to process enrollments or reimbursements if the forms submitted by the Plan
Administrator/Plan Sponsor do not comply with the Contract Administrative Firm's requirements.
D. Process Reimbursement Requests, including the provision of written instructions to participants for re -submitting requests in
instances where required information may be missing. In the event of an appeal by a participant, the Contract Administrative
Firm agrees to reimburse expenses based on final claims approval provided by the Plan Administrator/Plan Sponsor.
E. The Contract Administrative Firm will use the Plan Administrator/Plan Sponsor's Flexible Benefit Plan checking account or
make other arrangements with such employer, as so directed by the Plan Administrator/Plan Sponsor, in order to process
participant reimbursements. See Exhibit C. If the benefits card is contracted, the Plan Administrator/Plan Sponsor will fund
that account via ACH transfer directly to the benefits card provider.
F. Provide a check register or similar report to the Plan Administrator/Plan Sponsor for all transactions posted during each
processing period.
G. Conduct Non-discrimination testing on the 125 Plan(s), based on information provided by the Plan Administrator/Plan Sponsor,
and provide Plan Administrator/Plan Sponsor with a written interpretation following each open enrollment period.
H. Provide sample forms for the Plan Administrator/Plan Sponsor to communicate participant terminations and qualifying change
in status events to the Contract Administrative Firm.
Provide a year-to-date report of account balances, reimbursements paid, and scheduled payroll contributions amounts for all
1112512008 AumINISMA IvE SERVICES
participants enrolled in the Flexible Spending Accounts for each month.
J. Provide preparation of IRS Form 5500, if applicable, following the close of each Plan Year.
K. The Contract Administrative Firm will attend any audit or hearing held by a government agency or bureau regarding
compliance issues directly pertaining to administration services performed by Contract Administrative Firm during the term of
this Agreement and will provide any and all requested documents in their possession. This provision will survive the expiration
or termination of this Agreement.
2. Business Associate Contract Provisions:
A. All definitions referred to in the Business Associate Contract Provisions of this Agreement shall have the same meaning as
those described in 45 CFR §§ 160.103, 164.103, 164.304 and 164.501.
B. Obligations and Activities of Business Associate in accordance with HIPAA regulations regarding Protected Health Information
(PHI) and Electronic Protected Health Information (EPHI):
(i) Business Associate agrees to not use or further disclose Protected Health Information other than as permitted or
required by the Agreement or as required by law.
(ii) Business Associate agrees to use appropriate safeguards to prevent use or disclosure of the Protected Health
Information other than as provided for by this Agreement.
(iii) Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is known to Business
Associate of a use or disclosure of Protected Health Information by Business Associate in violation of the
requirements of this Agreement.
(iv) Business Associate agrees to report to Covered Entity any use or disclosure of the Protected Health Information not
provided for by this Agreement for which it becomes aware,
(v) Business Associate agrees to ensure that any agent, including a subcontractor, to whom it provides Protected
Health Information received from, created or received by Business Associate on behalf of Covered Entity agrees to
the same restrictions and conditions that apply through this Agreement to Business Associate with respect to such
information.
(vi) Business Associate agrees to make internal practices, books, and records relating to the use and disclosure of
Protected Health Information received from, or created or received by Business Associate on behalf of, Covered
Entity available to the Covered Entity, or at the request of the Covered Entity to the Secretary, in a time and manner
designated by the Covered Entity or the Secretary, for purposes of the Secretary determining Covered Entity's
compliance with the Privacy Rule.
(vii) Business Associate agrees to document such disclosures of Protected Health Information and information related to
such disclosures as would be required for Covered Entity to respond to a request by an Individual for an accounting
of disclosures of Protected Health Information in accordance with 45 CFR §164.628.
(viii) Business Associate agrees to implement any and all administrative, technical and physical safeguards necessary to
reasonably and appropriately protect the confidentiality, integrity and availability of electronic Protected Health
Information that it creates, receives, maintains or transmits on behalf of Covered Entity.
(ix) Business Associate agrees to ensure that access to Electronic Protected Health Information related to the Covered
Entity is limited to those workforce members who require such access because of their role or function.
(x) Business Associate agrees to implement safeguards to prevent its workforce members who are not authorized to
have access to such Electronic Protected Health Information from obtaining access and to otherwise ensure
compliance by its workforce with the Security Rule..
(A) Business Associate agrees to ensure that any agent, including a subcontractor, to whom it provides Electronic
Protected Health Information (`ePHI") received from, or created or received by Business Associate on behalf of,
Covered Entity agrees to implement appropriate safeguards to protect the ePH I.
(xii) Business Associate agrees to report to Covered Entity, in writing, any security incident of which it becomes aware.
Security incident shall mean successful unauthorized access to, disclosure, modification or destruction of, or
interference with, the Electronic Protected Health Information by a third party. In such instances, Business
Associate shall identify: the date of the security incident, the scope of the security incident, the Business Associate's
response to the security incident and the identification of the party responsible for causing the security incident, if
known.
(xiii) Upon request from Covered Entity, Business Associate agrees to provide information to Covered Entity on
unsuccessful unauthorized access, use, disclosure, modification or destruction of the Electronic Protected Health
Information to the extent such information is available to Business Associate. Business Associate reserves the right
to provide such information on a monthly basis as an aggregate number.
(xiv) As required by the Security Rule, Business Associate agrees to treat a material breach of this Agreement as a
breach of the Agreement and to an early termination of the Agreement by Covered Entity,
1112512008 ADMINISTRATIVE SERVICES
C. Permitted Uses and Disclosures by Business Associate
Except as otherwise limited in this Agreement, Business Associate may use or disclose Protected Health Information to
perform functions, activities, or services for, or on behalf of, Covered Entity as specified in this Agreement, provided that such
use or disclosure would not violate the Privacy Rule if done by Covered Entity,
3. The Contract Administrative Firm is willing to perform the services described in this Agreement, provided that Contract Administrative
Firm shall not assume the responsibilities of the Plan Administrator/Plan Sponsor under the Plan, and provided that Contract
Administrative Firm shall not constitute or be deemed or construed to constitute the "Plan Administrator" of the Plan as such term is
defined in the Plan and within the meaning of ERISA Section 3(16), The Contract Administrative Firm will use reasonable care and due
diligence in the performance of its responsibilities hereunder. In addition, except as expressly set forth herein, the Contract
Administrative Firm shall not be a "fiduciary" of the Plan as such term is defined in ERISA Section 3(21). Plan Administrator/Plan
Sponsor agrees that this responsibility is, and remains, that of the Plan Administrator/Plan Sponsor.
4. In accordance with the terms and conditions of this Agreement, the Plan Administrator/Plan Sponsor agrees to the following:
A. The Plan Administrator/Plan Sponsor desires to engage the Contract Administrative Firm to provide professional services in
accordance with this Agreement, and the Contract Administrative Firm desires to accept such engagement.
B. The Plan Administrator/Plan Sponsor shall administer the Plan or appoint a person or committee to administer the Plan (the
"Plan Administrator").
C. The Plan Administrator/Plan Sponsor understands and acknowledges that Contract Administrative Firm is responsible only for
providing the services specifically allocated to the Contract Administrative Firm in this Agreement.
D. If using a vendor for electronic enrollment for your group health benefits, the Plan Sponsor/Plan Administrator shall remain
ultimately responsible for the accuracy of the Flexible Benefit Plan elections and all related records. The Plan Sponsor/Plan
Administrator is responsible for capturing all electronic enrollment data and transmitting it to the Contract Plan Administrator
riot to the appropriate effective dates. The Plan Sponsor/Plan Administrator is responsible to review such reports and to
provide corrections as needed. The Contract Plan Administrator will continue to provide all reporting as outlined in this
Agreement.
E. The Plan Administrator/Plan Sponsor agrees to have the sample Plan Documents provided by the Contract Administrative
Firm reviewed and approved by the Plan Sponsor's legal counsel. Upon this review, the Plan Administrator/Plan Sponsor
agrees to supply the executed Plan Documents for review by participants upon request within a reasonable amount of time.
In addition, the Plan Administrator/Plan Sponsor agrees to provide a Summary Plan Description to each participant upon
enrollment in the Plan and to communicate any changes which may be made to the Plan and/or the Summary Plan
Description accordingly.
The Plan rAdministrator/Plan Sponsor shall establish a zero -balance Flexible Benefit Plan checking account or make other
arrangements with such employer in order for the Contract Administrative Firm to process claims for reimbursement under the
Plan (See Exhibit C).
G. The Plan Administrator/Plan Sponsor shall report all participant terminations and all qualifying change in status events in a
written format, including all requested information, to the Contract Administrative Firm prior to the first affected payroll date.
Should this information not be provided in a complete or timely manner, the Plan Administrator/Plan Sponsor agrees to pay
any resulting administrative fees which may be incurred in order to process retroactive adjustments to payroll contributions or
reimbursement claims processed in error.
H. The Plan Administrator/Plan Sponsor shall provide the Contract Administrative Firm, confirmation of redirections into the
Flexible Benefit Plan, based on reports provided by the Contract Plan Administrative Firm, in a timely manner, thus allowing
the Contract Administrative Firm to post contributions for the purpose of processing reimbursements. Should this information
not be received in a complete and timely manner, the Plan Administrator/Plan Sponsor agrees to pay any resulting
administrative fees required to process any retroactive changes, as fees for this service are not covered under this Agreement.
The Plan Administrator/Plan Sponsor agrees to provide to the Contract Administrative Firm, upon each open enrollment period
and with each new enrollment in the Plan, all required data to perform IRS -required 125 Plan Non-discrimination Testing. The
Plan Administrator/Plan Sponsor agrees to report any changes to the Contract Administrator, which may affect the qualification
of the Plan for meeting Non-discrimination requirements. In addition, the Plan Administrator/Plan Sponsor agrees to initiate
('*Wi6-0E
1112512008 ADMINISMAI NE 5ERVIL'E5
any action required in the event the Plan is reported as discriminatory.
J. The Plan AdministratodPlan Sponsor shall retain documentation relating to Plan operations that may be requested in an IRS
or Department of Labor audit of Plan operations - including, but not limited to: Non-discrimination testing information, executed
copies of the Plan, Salary Redirection Agreements ("Enrollment Forms"), Plan Amendments, Resolutions adopting the Plan,
and Form 5500s, (if applicable), for seven years after the close of each Plan Year.
K. The Plan Administrator/Plan Sponsor shall ensure that only common law employees participate in the Plan [employees of
companies described in IRC Section 414 (b), (c) or (m) and listed in the Plan as participating affiliates may also participate]
and to ensure that the terms of its Plan Document are properly enforced.
L. The Plan Administrator/Plan Sponsor shall provide all requested information on a timely basis for Igoe Administrative Services
to file an annual Form 5500 Return, if applicable, for the cafeteria plan within seven months following the close of each plan
year. In addition, the Plan Sponsor may be required to provide requested information in order for Igoe Administrative Services
to file Form 5500 Annual Returns for the component benefit plans offered through the cafeteria plan, (component benefit plans
would be a multiple plan including Premium Conversion Plans, Dependent Care FSA and/or Medical FSA).
M. The Plan Administrator/Plan Sponsor shall provide the required information on a timely basis in order for Igoe Administrative
Services to perform Non-discrimination testing required by the Internal Revenue Code for 125 Plan(s) (including, but not
limited to: ensuring that a non-discriminatory classification of employees is eligible for the plan, that contributions and benefits
do not discriminate in favor of highly compensated employees, and that no more than 25% of the total pre-tax benefits is
received by officers and owners). Additional information may be required in order for Igoe Administrative Services to conduct
Non-discrimination testing for the component benefits offered through the cafeteria plan (including insurance and flexible
spending account benefits). Igoe Administrative Services will perform Non-discrimination testing shortly after enrollment.
N. At each month -end the Contract Administrative Firm will submit a statement showing the amount of fees for that month
pursuant to Exhibit A. The Plan Administrator/Plan Sponsor will pay the Contract Administrative Firm the full amount within 10
days. Payments will be considered late after 30 days. If payment is not made within 30 days, the Contract Administrative firm
reserves the right to suspend future services. To reinstate services, the Plan Administrator/Plan Sponsor must agree to pay
the Contract Plan Administrative Firm via ACH for all future administrative fees.
0. (If Applicable) — If a Flex Plan participant uses his/her Flex benefits card for a transaction that falls outside of the benefits card
parameters set forth by the IRS, a request for substantiation will be sent automatically via e-mail. If no response is received
within 14 days a second electronic letter will be sent. If no response is received within 7 days, the benefits card will be
deactivated and the expense deemed ineligible.
Once a card is deactivated, the participant will no longer have the ability to use their card until he/she provides resolution
through one of the following methods:
Provide receipts as substantiation to Igoe Administrative Services along with a copy of the letter he/she received. The
information may be faxed to 858-777-5424. Upon receipt, the transaction will be approved therefore reactivating the
benefits card.
• Refund the Flexible Benefit Plan equal to the amount of the transaction via either a payroll deduction or a personal
check. Upon notification from the employer that the refund is complete, the transaction will be reversed therefore
reactivating the benefits card.
• The employer may add the amount of the ineligible transaction to the employee's W-2 as taxable income. Upon
notification from the employer that this action is being taken, the transaction will be approved therefore reactivating the
benefits card.
5, Obligations of Covered Entity in accordance with HIPAA regulations regarding Protected Health Information (PHI):
A. Covered Entity shall notify Business Associate of any restriction to the use or disclosure of Protected Health Information that
Covered Entity has agreed to in accordance with 45 CFR 164.522, to the extent that such restriction may affect Business
Associate's use or disclosure of Protected Health Information.
B. Covered Entity shall not request Business Associate to use or disclose Protected Health Information in any manner that would
not be permissible under the Privacy Rule if done by Covered Entity.
1112512008 ADMINISTRATIVE SERVIL"ES
6. Plan Administrator/Plan Sponsor acknowledges that they have read this Agreement in its entirety and Plan Administrator/Plan Sponsor
acknowledges that it has been advised to consult with, and has consulted as it deems necessary, its own attorney with respect to the
matters herein, and acknowledges that Contract Administrative Firm is not providing any tax or legal advice as a result of its professional
services under this Agreement. In addition, the Plan Administrator/Plan Sponsor agrees to the fees outlined in Exhibit A and Exhibit B of
this Agreement. Failure to pay fees when due may result in termination of this Agreement. The Administrative Fee Schedule, which is
attached to this Agreement as Exhibit A, is made a part hereof as of the effective date of this Agreement.
7. Should either party institute legal action to enforce its rights under this Agreement, the venue shall be in San Diego County, State of
California, and the prevailing party in such action shall be entitled to recover reasonable attorney's fees and costs.
8. Should Plan Administrator/Plan Sponsor, at any time during the coverage period of this Agreement, file in the United States for the Debt
Relief or Reorganization of any type, all services from the date of the filing forward shall be terminated immediately.
9. Plan Administrator/Plan Sponsor agrees to accurately complete an administrative instruction/summary form, as supplied by the Contract
Administrative Firm, upon implementation or renewal of the Plan. Plan Administrator/Plan Sponsor agrees that these forms Will provide
the basis of the Contract Administrative Firm's administrative actions under this Agreement, Further, Plan Administrator/Plan Sponsor
agrees that any changes to the information supplied on these forms may only be made in writing and are only effective when
acknowledged by the Contract Administrative Firm in writing. Additional fees may be incurred for any retroactive changes made after
the Plan Administrator/Plan Sponsor has agreed to the administration design in writing or for any changes which may be requested mid-
year (after the open enrollment period).
10. Term and Termination.
A. Term. This Agreement shall govern the contract period beginning January 1, 2009 and ending December 31, 2009, unless
terminated earlier by either party at any given time upon thirty (30) days written notice.
B, The Term of this Agreement shall be effective as of the date of the signature on this Agreement, and, with respect to HIPAA
Privacy Rules, this Agreement shall terminate when all of the Protected Health Information provided by Covered Entity to
Business Associate, or created or received by Business Associate on behalf of Covered Entity, is destroyed or returned to
Covered Entity, or, if it is infeasible to return or destroy Protected Health Information, protections are extended to such
information, in accordance with the termination provisions in this Section.
C. Termination for Cause. With respect to HIPAA Privacy Rules, upon Covered Entity's knowledge of a material breach by
Business Associate, Covered Entity shall provide an opportunity for Business Associate to cure the breach or end the violation
and terminate this Agreement and the Administrative Services Agreement if Business Associate does not cure the breach or
end the violation within the time specified by Covered Entity, or immediately terminate this Agreement and the Administrative
Services Agreement sections if Business Associate has breached a material term of this Agreement and cure is not possible.
D. Effect of Termination.
Except as provided for above with respect to HIPAA Privacy Rules, upon termination of this Agreement, for any
reason, Business Associate shall return or destroy all Protected Health Information received from Covered Entity, or
created or received by Business Associate on behalf of Covered Entity. This provision shall apply to Protected
Health Information that is in the possession of subcontractors or agents of Business Associate. Business Associate
shall retain no copies of the Protected Health Information.
In the event that Business Associate determines that returning or destroying the Protected Health Information is
infeasible, Business Associate shall provide to Covered Entity notification of the conditions that make return or
destruction infeasible. Upon mutual agreement of the Parties that return or destruction of Protected Health
Information is infeasible, Business Associate shall extend the protections of this Agreement to such Protected Health
Information and limit further uses and disclosures of such Protected Health Information to those purposes that make
the return or destruction infeasible, for so long as Business Associate maintains such Protected Health Information.
11. Miscellaneous.
A. Applicable Law. This Agreement shall be governed by and construed in accordance with the laws of the State of California.
B. Assignability. This Agreement and the rights, benefits, privileges, duties and responsibilities of the parties hereto may not be
assigned by any other party hereto without the prior written consent of the parties hereto.
1112512008 AUMINIS'fRATIVE SERVILES
C. Amendment. In regard to Protected Health Information (PHI), the Parties agree to take such action as is necessary to amend
this Agreement from time to time as is necessary for Covered Entity to comply with the requirements of the Privacy Rule and
the Health Insurance Portability and Accountability Act, Public Law 104-191.
D. Binding Nature of Agreement. This Agreement is binding upon signature by both parties and shall inure to the benefit of the
heirs, executors, successors and assignors of the parties hereto.
E. Comvllete Agreement, This Agreement and all accompanying Exhibits constitute the complete Agreement of the parties
regarding its subject matter and replaces and supersedes any prior written or oral agreement between the parties regarding its
subject matter.
F. Confidentiality. The Contract Administrative Firm will maintain the confidentiality of all records and information obtained in
conjunction with the services to be performed hereunder in accordance with HIPAA Privacy regulations. The information
therein shall not be divulged or disclosed or made available to persons, other than the Plan Sponsor/Plan Administrator,
without written approval by the Plan Sponsor/Plan Administrator or a court of competent jurisdiction. This paragraph will
survive the termination or expiration of the Agreement.
G. Construction and Severabili!y, The captions of this Agreement and its paragraphs and Subparagraphs are for the convenience
of the parties only and shall not be taken in account in the construction and interpretation of this Agreement. The terms of this
Agreement are severable; should any portion of this Agreement be invalid or unenforceable, such invalidity or unenforceability
shall not affect the validity or enforceability of the remainder of this Agreement and this Agreement shall be construed and
interpreted as though such invalid or unenforceable provision was not contained herein.
H. Independent Contractor. The Contract Administrative Firm's relationship with Plan Administrator/Plan Sponsor is that of
independent contractor and nothing in this Agreement shall be construed as creating the relationship of employer or employee
between the Plan Administrator/Plan Sponsor and officers, employees, or agents of the Contract Administrative Firm or the
relationship of a partnership or joint venture between the parties, as outlined in Section 4 of this Agreement.
I. Interpretation. In regard to Protected Health Information (PHI), any ambiguity in this Agreement shall be resolved in favor of a
meaning that permits Covered Entity to comply with the Privacy Rule.
J. Modifications. This Agreement may not be modified or amended except by means of written modification or amendment of
this Agreement or their legal successors in interest.
K. Regulatory References. All references in this Agreement to a section in the Privacy Rule means the section as in effect or as
amended, and for which compliance is required under the Health Insurance Portability and Accountability Act, Public Law 104-
191.
L. Survival. The respective rights and obligations of Business Associate under HIPAA Privacy Rules, as outlined in this
Agreement, shall survive the termination or expiration of this Agreement.
M. Warranties. No representations or warranties have been provided by any party to this Agreement or to any other party to this
Agreement except as specifically set forth in this Agreement.
12. Indemnification of the Contract Administrative Firm ('Business Associate") and the Plan Administrator/Plan Sponsor ("Covered Entity")
Contract Administrative Firm/Business Associate shall indemnify, defend and hold harmless Plan Administrator/Plan Sponsor, its
affiliates, directors, officers and employees or any of them from any claim, expense, loss, damage, settlement, judgment, penalty and
liability, including reasonable attorneys' fees and court costs (individually and collectively, "Claims") resulting in any way from or arising
out of Contract Administrative Firm's/Business Associate's performance of or failure to perform this Agreement, including, without
limitation, Claims resulting from or arising out of acts or omissions by Contract Administrative Firm/Business Associate, its employees,
officers, directors, agents, or other individuals who provide services under this Agreement.
Plan Administrator/Plan Sponsor shall indemnify, defend and hold harmless Contract Administrative Firm/Business Associate, its
affiliates directors, officers and employees or any of them from any claim, expense, loss, damage, settlement, judgment penalty and
liability including reasonable attorney's fees and court costs (individually and collectively, "Claims") resulting in any way from or arising
out of Plan Administrator's/Plan Sponsor's performance of or failure to perform this Agreement, including, without limitation, Claims
resulting from or arising out of acts or omissions by Plan Administrator/Plan Sponsor, its employees officers, directors, or agents.
Cj 1-* -6 0 E
1112512008 ADMINISTRATIVE SERVICES
The Parties to the agreement consent and agree to all of the provisions and by their signature cause this Agreement to
become effective as of the date of signature. Remittance of and acceptance of payment for services hereby binds both parties
to this agreement.
City of Vernon Amended and Restated Flexible Benefit Plan
("Covered Entity")
AND
%,-7,xxxxxxxxxxxxxxxxxxxxxxxxxxxx
®awxxxxxxxxxxxxxxxxxxxxxxxxxxx
A TEST: Plan Sponsor/Plan Administrator:
City of Vernon
MANUELA GIRON, Ci y Clerk
APPROVEDAS TO FORM: By;
L onis C. alb erg, Ma or
JE RRISON, City Attorney
Date: �v !�,r
Contract Administrative Firm
(`Business Associate")
By:
Date: November 25, 2008
C,
,1,61TAC
1112512008 ADMINISTRATIVE SERVICES
EXHIBIT A: ADMINISTRATIVE FEE SCHEDULE
City of Vernon
RATES EFFECTIVE JANUARY 1, 2009
MONTHLY ADMINISTRATIVE CHARGES — Flexible Spending Accounts
Monthly Administration Fee: $200.00*
TRANSPORTATION FRINGE BENEFITS (If applicable)
A monthly service charge of $75.00 will apply for the maintenance of the Transportation Benefit
LIMITED PURPOSE FSA (If applicable)
A monthly service charge of $75.00 will apply for the maintenance of the LPFSA Benefit
ADMINISTRATIVE SERVICES INCLUDED IN ABOVE FEE
The following services are included in the monthly administration fee
Actual Postage Expenses
INCLUDED
Multiple Payroll Cycles
INCLUDED
For example: weekly & bi-weekly, monthly & weekly, etc,
Plan Year End Run Out Period Processing
INCLUDED
Igoe Administrative Services will process Run Out Period reimbursement submittals on a set administrative
schedule.
2.5 Month Grace Period Processing (Extension Period)
INCLUDED
Igoe Administrative Services will process the up to 2,5 Month Grace Period (formerly known as the Extension
Period) reimbursement submittals on a set administrative schedule,
Electronic Enrollment Confirmation
INCLUDED
Igoe Administrative Services will send an enrollment confirmation at the start of the plan year to all plan
participants that provide an e-mail address.
Electronic Plan Year End Reminder Notification
INCLUDED
Igoe Administrative Services will send a reminder notification including run out deadlines to all plan
participants that provide an e-mail address.
Non -Discrimination Re -Testing (125 Plans)
INCLUDED
Applies when retesting is required due to client not providing requested data at Open Enrollment, or anytime
during the year when the client requests the Plan(s) to be retested
Flex Benefits Card Reactivation (if applicable)
INCLUDED
A Flex Benefits Card may become de -activated if an employee does not comply with Flex Benefits Card
requirements
Flex Benefits Card Replacement (if applicable)
INCLUDED
Applies when a Flex Benefits Card is lost or stolen & client requests replacement card
"If plan participation changes by 10% or more during this contract period, Igoe Administrative Services reserves the right to adjust the monthly
administration fee by the exact percentage of the participation change.
1112512008 AUMINIsrHAINE 5ERVIL'E5
ANNUAL RE -ENROLLMENT FEE
Provided Igoe Administrative Services and the client mutually accept future services; Igoe Administrative Services reserves the right to charge an
Annual Enrollment Fee. The client will be provided with a proposal of fees for the new Plan Year no later than 60 days before the end of the
current Plan Year. All fees for services must be paid in full prior to the preparation of any renewal materials. Included services are:
♦ Load -on of all new enrollments and building of new database for each Plan Year
♦ Add new participants after initial set up of Plan
♦ Preparation of new master enrollment materials
The minimum monthly fee will apply when a client chooses not to renew for the next Plan Year and requests Igoe Administrative Services to
administer the Plan Year Run Out Period for the ending Plan Year.
OPTIONAL ADMINISTRATIVE FEES
The following services are not included in the administration fees. The client will incur additional fees when these
services are required or requested.
Any services not explicitly outlined in this Agreement may require additional fees. Optional services may include, but are not limited to, Specialized
Reporting, Additional Services, Information Systems Programming or Consultation. Fees for these services will be determined based on the time
required to complete said service and will be agreed to by both parties prior to performance of such services.
Special Check Run
$25.00
Checks produced on non-scheduled processing day - Additional fees will apply when client requests
PER SPECIAL RUN
replacement checks be generated prior to next scheduled processing day
Flex Benefits Card Set -Up
$100.00
If client implements the Flex Benefits Card
Flex Plan Document Amendments/Restatements
$150.00
Applies when a Plan Document Amendment is necessary to keep your Plan in compliance
WebEx
ADDITIONAL FEES MAY APPLY, PLEASE
Professionally trained Igoe staff members are available by appointment to conduct a live, interactive
CONTACT YOUR ACCOUNT MANAGEMENT
enrollment/client education/ or participant education meeting via the Internet. The length of the call and the
TEAM TO OBTAIN A QUOTE
number of connections included determine the fees for this service.
1112512008 ACIMINISTRATIVE SERVICES
EXHIBIT B: ADMINISTRATIVE SERVICES
ON -GOING ADMINISTRATIVE SERVICES
The following services are included in the administration fees.
RV'e_vv'Online Employer Access To Documents and Reports
The site allows you to view all customized forms, reports and documentation regarding your Flex Plan. Access
to this site will be restricted by 128-bit encrypted super -certificate from Thawte to ensure the strongest possible online
security. Your Account Management Team will provide a demonstration of this site upon implementation.
24-Hour On -Line Participant Account Information
Participants are given online access with abilities to check account balance and transaction information via the Igoe
Administrative Services web site at www.goigoe.com. Upon enrollment for each new Plan year, all website login
information will be provided to you for distribution.
Participant Services
Igoe Administrative Services Participant Services Department is comprised of a team of qualified personnel available to
assist Participants by answering questions and resolving issues that may arise during the Open Enrollment Period and
throughout the Plan Year. The Participant Services Team is trained to respond to Participant issues such as: account
balance inquiries; contributions, reimbursements, requests posted to Participant accounts; questions on denied requests
for which a Participant has received a letter; education regarding eligibility of expenses; confirmation of processing
deadlines or reimbursement methods; and IRS Guidelines and Section 125 regulations.
Annual Non-discrimination Testing (When Required for 125 Plans)
Non-discrimination Testing will begin upon receipt of participant Enrollment Forms, elections and required IRS Non-
discrimination information. Three separate tests will be conducted following each Open Enrollment Period to ensure that
your Plan is in compliance with IRS Non-discrimination requirements, as follows:
♦ 25% Concentration Test: Testing is required to confirm that no more than 25% of the total benefit is
contributed by key employees.
♦ 55% Average Benefit Test: Testing is required to confirm that more than 55% of the average DCAP benefit
is contributed by non -highly compensated employees.
♦ 5% Owner Benefits Test: Testing is required to confirm that no more than 25% of the total DCAP benefit is
contributed by 5% owners of the firm.
Standard Reporting Services
♦ Provide reimbursement register or reimbursement report to coincide with processing schedule
♦ Provide monthly management report
♦ Provide annual IRS Form 5500 Reporting, if applicable
('Jrf-;jUjF
1112512008 ADMINISTRATIVE SERVICES
Ongoing Education
Through the Igoe Administrative Services web site: www.goigoe.com, Administrators, Participants and those interested
may access:
♦ Rules and Regulations governing IRS Section 125 Flexible Benefit Plans
Updated publications provided by the Internal Revenue Services (IRS)
♦ Links to the Internal Revenue Service (IRS)
♦ Frequently asked Questions with Answers
In addition, the viewer may download, free of charge:
♦ Medical Care Reimbursement Plan Worksheets
♦ Dependent Care Assistance Plan Worksheets
♦ Medical Reimbursement Plan Request Forms
♦ Dependent Care Assistance Plan Request Forms
♦ Dependent Care vs. Tax Credit Worksheet
♦ Sample Childcare Provider Receipt
Enrollment Materials
A Master set of Enrollment Materials are created by Igoe Administrative Services prior to each Open Enrollment Period
and forwarded to your firm via e-mail at no charge.
CJ4Fi�OE
1112512008 ADMINISTRATIVE SERVICE5
EXHIBIT C: FUNDING REQUIREMENTS
FUNDING OPTION 1-e PAYROLL REIMBURSEMENT:
The Plan Sponsor/Plan Administrator will maintain all FSA related funds, Igoe Administrative Services will provide
notification directly to the Plan Sponsor/Plan Administrator of all reimbursements to be included on the Plan Sponsor/Plan
Administrator's next scheduled pay date,
FUNDING OPTION 2 — MANUAL REIMBURSEMENT FROM PLAN SPONSOR ACCOUNT:
The Plan Administrator/Plan Sponsor shall establish a zero -balance Flexible Benefit Plan checking account and authorize
Michael C. Igoe as a signer. If Plan Administrator/Plan Sponsor does not want to add Michael C. Igoe as a signer on said
account, unsigned checks will be provided directly to the Plan Administrator/Plan Sponsor for signature and dispersment.
FUNDING OPTION 3 — MANUAL REIMBURSEMENT/DIRECT DEPOSIT FROM IGOE ACCOUNT:
Igoe Administrative Services will issue physical checks to Plan participants on behalf of the Plan Sponsor/Plan
Administrator. Reimbursement checks will be issued using Igoe Administrative Services contracted bank. The Plan
Sponsor/Plan Administrative will have a unique routing/account number to ensure that all plan related funds are held in
sole and separate accounts. The Plan Sponsor/Plan Administrator will prefund said account with one month's worth of
salary redirections (minimum of $5000.00 required) and agrees to replenish all funds used for Plan reimbursement within
2 business days of the check issuance date. Igoe Administrative Services reserves the right to suspend the delivery of
participant reimbursements if said account is not funded as required on the scheduled processing date.
Igoe Administrative Services will handle all banking related services such as but not limited to, stop payments, reissuance
of checks, research of stale dated checks, monthly account reconciliation.
FUNDING OPTION 4 — BENEFITS CARD:
Plan Sponsor/Plan Administrator will provide ACH abilities to Metavante/Medibank for the funding of benefit card
transactions only. This option can be paired with either of the above for non -benefits card transactions.
1112512008 ADMINISTRATIVE SERVICES
Wire Transfer Information
(Payment of Administrative Fees and/or Replenishment of Igoe Banking Account)
Please Type or Print Clearly
Client Name (party initiating wire transfer): CITY OF VERNON
Taxpayer Identification Number (TIN): 95-6000808
Company Contact Name for Remittance Only:
CLAUDIA LUNA
Company Contact Telephone Number: (323) 583-8811 ext. 200
Company Contact e-mail Address
cluna@ci.vernon.ca.us
Company Fax Number: (323) 826-1491
Igoe Administrative Services Wire Transfer. Information
Bank: California Bank and Trust
Bank Address: 11717 Bernardo Plaza Court, San Diego, CA 92128
Account Name: Igoe & Company, Incorporated
Routing Number: 122232109
Account Number: 21-101645-01
By signing this agreement, the above named client agrees to make payments
and/or replenish their Igoe maintained bank account within the time frame
outlined in the current Administrative Service Agreement. Client agrees to
email accounting(a�goigoe.com whenever a wire transfer is initiated confirming
the amount of the transfer and the purpose of the wire transfer. If the transfer
is meant to pay for administrative services, the invoice number must be
provided in the email notification. Furthermore client agrees to treat the above
information as confidential.
SHARON DUCKWORTH CITY TREASURER
Authorized Contact (Please print) Job Title
Authorized Signature Date
Please email this form to:
Igoe Administrative Services Accounting Department at accountinq(a?goigoe.com
If email is not an option, the form may be faxed to (858) 683-2053
FSA ENROLLMENT DATA FEED PROGRAM
DataFeed Overview ...............................................................
The new data feed system was developed with flexibility and security in mind; allowing you to easily create and transmit
your file over a 'secure connection. Data Feeds are simply a file or files that contain the information from your system
necessary to enroll your employees in one or more Flexible Spending Account Plans in our system.
Data Feeds should only consist of employees that are enrolling in at least one FSA plan. Your data should be sent using
two distinctly different record types. Igoe Administrative Services prefers that all files combine each record type in a
1,2,1,2 sequence. The first record type, called the Employee Record, will contain your employee's general information
such as the Social Security Number, name, and address. The second file, called the Elections Record, will include
enrollment information such as plan type, annual election, and per pay period election. The Elections Record should be
repeated for each benefit type being elected.
IMPORTANT NOTE: OPEN ENROLLMENT FILES SHOULD CONTAIN ALL RECORDS INDICATING A POSITIVE FSA ELECTION. FILES
USED FOR ONGOING ELIGIBILITY TRANSFERS CAN ONLY CONTAIN CHANGE ONLY RECORDS (EX: NEW ELECTIONS/NEW HIRES,
TERMINATIONS, CHANGE IN STATUS/QUALIFYING EVENTS, AND DEMOGRAPHIC CHANGES). IGOE ADMINISTRATIVE SERVICES DOES
NOT ACCEPT FULL FILES OUTSIDE OF OPEN ENROLLMENT.
Record 1: Employee Record.....................................................................
The Employee Record will consist of one row for each employee that will be enrolling in at least one FSA plan.
Note (Required fields are bold)
Field
Name
Data
Type
Max
Length
Formats
Description
SSIN
Text
11
999999999 or 999-99-
9999
Last Name
Text
20
First Name
Text
20
MI
Text
1
Middle Initial
Address
Text
30
Address2
Text
30
Use Address2 if your Address
field exceeds the 30 character
limit.
city
Text
25
State
Text
2
AZ, CA etc...
Any valid State code
Zip Code
Text
10
99999, 999999999 or
99999-9999
Hire Date
Date
mm/dd/yyyy or
mm/dd/yy
Pay Mode
I Text
2
Values (A,B,S,M,W)
Your code could vary
Payroll frequency
A=Annual B=Biweekl
1112512008 AUMINISMATIVE SERVICES
depending on your
S=Semimonthly M=Monthly
a roll frequencies
W=Weekl
Status
Text
1
A = Active
T = Termed
L = Leave of Absence
R = Return from Leave of
Absence*
C = Change in
status/demographic change'
Term Date
Date
10
mm/dd/yyyy or
The date that the employee
mm/dd/yy
termed either employment of
all benefits associated with
their record
First phone
Text
14
9999999999, 999-999-
#
9999 or (999) 999-
9999
Second
Test
14
9999999999, 999-999-
Phone #
9999 or (999) 999-
9999
Email
Text
30
user(ab. host. corn
This field is required if you
Address
are offering FSA debit cards
to your clients
First Pay
Date
10
mm/dd/yyyy or
The first pay day their
Date
mm/dd/yy
deductions will take place
Effective
Location
Text
2
Required if locations are
Code
tracked by Igoe
Division
Text
2
Required if divisions are
Code
tracked by Igoe
Department
Text
5
Required if departments are
Code
tracked by Igoe
Officer &
Text
1
Values (Y or N)
Y" if employee is an officer and
Over 150K
earns more than $130K; "N" if
they are not.
1 % owner
Text
1
Values (Y or N)
"Y" if employee is at least a 1 %
& over
owner and earns over $150K;
$150K
"N" if they are not
Over 5%
Text
1
Values (Y or N)
"Y" if employee is over 5%
owner
owner; "N" if they are not
Earns
Text
1
Values (H or N)
If employee is highly
105K
compensated use "H'; "N" if
they are not
*CAUTION — WHEN USING THE "R" STATUS, PLEASE ENSURE THAT ALL PREVIOUSLY MADE CONTRIBUTIONS ARE TAKEN INTO
CONSIDERATION WHEN CALCULATING THE PER PAY PERIOD INFORMATION ON THE ELECTIONS RECORD
**CAUTION — WHEN USING THE "C" STATUS FOR A QUALIFYING EVENT, PLEASE ENSURE THAT THE ACTUAL EFFECTIVE DATE
LISTED ON THE ELECTIONS RECORD INDICATES THE EFFECTIVE DATE OF THE STATUS CHANGE, NOT THE DATE THE CHANGE WAS
ENTERED OR THE ORIGINAL ELECTION EFFECTIVE DATE.
Mir grow
1112512008 AOMINI5TRATIVE 5ERVICES
Record2: Elections Record................................................................ .
The Elections Record will be associated to the Employee Record using the SSN. This means an employee must exist
on the Employee Record with the same SSN or the corresponding election(s) will not be added. If you have multiple
plans with Igoe Administrative Services then you could potentially have more than one election record for each
employee. An example of this would be if you had Medical and Dependent Care plans. To enroll an employee in both
plans they would have two rows providing election information for each plan.
Note (Required fields are bold)
Field Name
Data Type
Max Length
Formats
Description
SSN
Text
11
999999999 or 999-99-
This is used to link to
9099
an employee in the
Employee File. An
Employee must exist
in the Employee File
with this SSN or it
will not be added.
Plan Type
Text
1
Values (1 or 2)
1=Dependent Care
2 = Medical Care
Annual
Number
11
9999.99 or 9,999.99
Annual Election
Election
Pay Period
Number
11
9999.99 or 9,999.99
Amount deducted for
Deduction
each ay period.
Effective Date
Date
10
mm/dd/yyyy or mm/dd/yy
For Open
Enrollment = Date
new plan year will
start.
For new
hires/election
changes* = Date the
election is effective
from a regulatory
standpoint
'CAUTION — WHEN USING THE "R" STATUS, PLEASE ENSURE THAT ALL PREVIOUSLY MADE CONTRIBUTIONS ARE TAKEN INTO
CONSIDERATION WHEN CALCULATING THE PER PAY PERIOD ON THE ELECTIONS RECORD. WHEN USING THE "C" STATUS FOR A
QUALIFYING EVENT, PLEASE ENSURE THAT THE ACTUAL EFFECTIVE DATE LISTED ON THE ELECTIONS RECORD INDICATES THE
EFFECTIVE DATE OF THE STATUS CHANGE, NOT THE DATE THE CHANGE WAS ENTERED OR THE ORIGINAL ELECTION EFFECTIVE
DATE.
4,itruz
1112512006 AUMINI51HA'UVE SERVICES
(ist
IIFF17AE
ADMINUETRATIVE 5ERVICES
16769 Bernardo Center Drive Suite 21
San Diego, CA 92128
Attention: Flex Account Management Team
Karina Rueda
City of Vernon
4305 Santa Fe Ave
Vernon, CA 90058
If you have any questions concerning this invoice, please contact:
Your Account Management Team at flexsupport@goigoe.com
Tax ID:95-3391660
DATE: November 25, 2008
REFERENCE # November 25, 2008
FOR: City of Vernon 2009 Renewal
THANK YOU FOR YOUR CONTINUED BUSINESS!
PAY PERIOD PAYDATE
1.
12/07/08 -
12/20/08
01 /01 /09
2.
12/21 /08 -
01 /03/09
01 /15/09
3.
01 /04/09 -
01 /17/09
01 /29/09
4.
01 /18/09 -
01 /31 /09
02/12/09
5.
02/01/09 -
02/14/09
02/26/09
6.
02/15/09 -
02/28/09
03/12/09
7.
03/01/09 -
03/14/09
03/26/09
8.
03/15/09 -
03/28/09
04/09/09
9.
03/29/09 -
04/11/09
04/23/09
10.
04/12/09 -
04/25/09
05/07/09
11.
04/26/09 -
05/09/09
05/21 /09
12.
05/10/09 -
05/23/09
06/04/09
13.
05/24/09 -
06/06/09
06/18/09
14.
06/07/09 -
06/20/09
07/02/09
15.
06/21 /09 -
07/04/09
07/16/09
16.
07/05/09 -
07/18/09
07/30/09
17.
07/19/09 -
08/01/09
08/13/09
18.
08/02/09 -
08/15/09
08/27/09
19.
08/16/09 -
08/29/09
09/10/09
20.
08/30/09 -
09/12/09
09/24/09
21.
09/13/09 -
09/26/09
10/08/09
22.
09/27/09 -
10/10/09
10/22/09
23.
10/11 /09 -
10/24/09
11 /05/09
24.
10/25/09 -
11 /07/09
11 /19/09
25.
11 /08/09 -
11 /21 /09
12/03/09
26.
11 /22/09 -
12/05/09
12/17/09
27.
12/06/09 -
12/19/09
12/31 /09
MEMORANDUM
Risk Management
TO: Jeff Harrison, City Attorney
FROM: Willard G. Yamaguchi, Risk Manager A6
DATE: November 18, 2008
RE: Flexible Spending Account
IGOE Administrative Services
APPROVED NOV 2 4 '08 CITY COUNCIL
CITY C, ERK ISs_TR,�BUTION
Utf
res. q'1.l I
It is hereby recommended that the City Council approve the renewal of the Flexible Benefit Plan
Administrative Services Agreement for the plan year beginning January 1, 2009 and ending December
31, 2009.
The renewal fees remain the same as last year and consist of a $300.00 renewal fee and a monthly
administration fee of $200.00 with a total yearly cost of approximately $2,700.00 plus additional
services as requested.
WGY/kr
cc: Judy Lehr