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r-', 1""", City of Fort Walton Beach d~ c ~~~~~) 1 v~ 94- 10 A RESOLUTION OF THE CITY OF FORT WALTON BEACH. OKAlOOSA COUNTY. PIING. FOR' THE: E:.. P- l- FlOIHOA.,-' :AI;)() oYE S-: OF . JHECIJY " J\ FL,~~H~L,E aUiEfHSP~ I. ,~ OYJ.PED:, ay ,~~ E~ JCAN, lA" KERS, I,. JFE AS$ I:JR. A~GE IP~ tfLOF: flORI~A:: P~ QVID:1t4G A" EffECTI~ E: PA.TE.' . I. the ' C' ity' of "Fort' Walton Beach"' has WHEREAs. a number of employees renderi:l1gv~luable services to the City: and WHEREAS. the Council has found and determined that the City estab1i~ hmel1t of flexible benefits plan providing group medical and a other insurance for the employees of the City serves the interest of the City by protecting the employees and by assisting in the attraction and retention of competent personnel: and the City Council has further found and determined that WHEREAS. such plan within the context of Section 125 of the establi:shil19 Internal Revenue Code for the benefit of the City' s el igib1:e employees provides certain tax advantages to the City and to its employees: and WHEREAS. the City has reviewed such flexible benefits plans from vario~s,~ orporations providing the said plans and has determined that the establishment of a flexible benefits plan with American Bankers Life Assurance Company of Florida ( ABLAC) is consistent with theCity' s objectives with respect : to employeepenefits and is in the. best interests of the City and its employees. NOW. THEREFORE. BE IT RESOLVED BY THE CITY COUNCil OF THE CITY OF FORT A~ TON.. B:EACH. hat -' OKALOOSA C{)UNTY.' FlORIDA: t- SECTION I: The" City of Fort Wal ton Beach hereby adopts the flexibl~' benefits plan attached hereto as Exhibit " A". and provided by ABLAC. The effective date of the said plan shall be' the earliest date such plan can be administratively implemented as a matter of law. SECTION II: The City hereby designates and authorizes the City Manag~ r: 0.1':' ~ nY other person designated by the City Manager to be the administrator of the said flexible benefits plan. The City Manager or such desi gnee shall recei ve any and all necessary reports. noti ces. and other documentation with respect to the said plan and , shall make on behal f of the City any and all necessary admini strati ve deci si ons required to implement and administer the plan. SECTION The City Manager is hereby authorized and directed III: t~ Qn behal f of the City the adoption and i mpl ementati on of the to exe. GL,. flexible benefits plan. SECTION IV: Thi s resol ut i on shall take effect i mmedi atel y upon approvaJ', py: Council and signature of the Mayor. ADOPT ED : MAYOR: form and legal sufficiency of fore 01 ng has been revi ewed and by the City Attorney. LITHO . v VITIIO "" Eas C 0 I EKW"A { CAFETERIA PLAN For the Employees of ABC Company Plan Number 4 501 Ml'[ 0 c o This Cafeteria Plan Prepared on Behalf of ABC Company Plan Administrator of the ABC Company Cafeteria Plan Is Hereby Adopted in its Entirety COPIES OF THIS CAFETERIA PLAN AND ALL SUPPORTING INSTRUMENTS ARE MAINTAINED ON FILE BY THE PLAN ADMINISfRATOR. ABC Company Plan Administrator By: Date: c o ABC Company Cafeteria Plan Summary Plan Description NAME OF THE PLAN: ABC Company Cafeteria Plan NAME, ADDRESS AND TELEPHONE NUMBER OF EMPLOYER: ABC Company 101 Main St Miami, FL 33235 ( 305) 555- 7878 EMPLOYER IDENTIFICATION NUMBER: 66- 3434221 FLAN NUMBER ASSIGNED BY THE PLAN SPONSOR: 501 PLAN SITUS: FL TYPE OF EMPLOYEE WELFARE PLAN: Cafeteria Plan TYPE OF ADMINISTRATION FOR THE PLAN: Contrnct Administration NAME, ADDRESS AND TELEPHONE NUMBER OF THE PLAN ADMINISfRA TOR: ABC Company 101 Main St Miami, FL 33235 ( 305) 555- 7878 NAME, ADDRESS AND TELEPHONE NUMBER OF PLAN COORDINATOR: Insurance Systems Group, Inc. P. O. Box 50387 Raleigh, NC 27650 ( 919) 834-4907 NAME, ADDRESS AND TELEPHONE NUMBER OF PLAN TRUSI'EE( S): Joe Bob Briggs Jim Morrison Peter Frampton 101 Main St. 101 Main St. 2342 Main 5t Miami FL 33235 Miami FL 33235 Clark Gables FL 12331 919) 555- 7878 ( 919) 555- 7878 919) 123- 3232 EFFECTIVE DATEOF THE PLAN: 02/ 01/94 END OF PLAN YEAR: 01/31 NAME, ADDRESS AND TELEPHONE NUMBER OF PLAN' S AGENT DESIGNATED TO ACCEPT LEGAL ROCESS: Jean Ames 101 Mliin St. Miami, FL 33235 919) 323-4591 Note: service of legal process may ulso be madc upon : 1 plan tmstee or the plan adminislmlor. c o STATEMENT OF ERISA RIGHTS As a participant in ABC Company' s Cafeteria Plan, you are entitled to certain rights and protections under the Employee Retirement Security Act of 1974 [- ERISA -]. ERISA provides that all plan participants shall be entitled to: Examine, without charge, at the plan administrator' s office and at other specified locations, such as worksite. s and union balls, all plan documents, including insurance contracts, collective bargaining agreements and copies of all documents filed by the plan with the U. S. Department of Labor, such as detailed annual reports and plan descriptions. Obtain copies of all plan documents and other plan information upon written request to the plan administrator. Tbe administrator may make a reasonable cbarge for copies. Receive a sunuoary of the plan' s annual fmancial report. Tbe plan administrator is required by law to furnish eacb participant with a copy of this summary annual report. In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the ABC Company Cafeteria Plan. The people who operate your plan, called - fiduciaries- of the plan, have a duty to do so prudently and in the interest of you and plan othe>: particit'ants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining any benefit under the ABC Company Cafeteria Plan or exercising your rights under ERISA. If your claim for a benefit under the Plan is denied in whole or in part you must receive a written explanation of the reason for the denial. You bave the right to bave the plan review and reconsider your claim. Under ERISA, there are steps you can take to enforce the above rigbts. For instance, if you request materials from the plan and do not receive them within 30 days, you may fiJe suit in a federal court. In sucb a case, the court may require the plan administrator to provide the materials and pay you up to $ 100 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits whicb is denied or ignored, in whole or in part, you may file suit in a state or federal court. If it should happen that plan fiduciaries misuse the plan' s money, or if you are discriminated against for asserting your rigbts, you may seek assistance from the U. S. Department of Labor, or you may file suit in a federal court. The court will decide wbo should pay court costs and legal fees. If you are successful the court may order the person you bave sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if the court finds your claim is frivolous or without any merit. If you have any questions about your Plan, you should contact the plan administrator. If you have any questions about this statement or about your rights under ERISA, you should contact the nearest Area Office of the U. S. Labor- Management Services Administration, U. S. Department of Labor. c o CAFETERIA PLAN INTRODUCTION ABC Company ( the " Employer") hereby establishes a flexible benefit plan for its Employees. This Plan shall be known as ABC Company Cafeteria Plan ( the " Plan"). The intention of the Employer is that the Plan qualify as a " Cafeteria Plan" within the meaning of Section 125 of the Internal Revenue Code of 1986, as amended, and that the benefits which an Employee elects to receive under the Plan be includable or excludable from the Employee' s income under Section 125( a) and other applicable sections of the Internal Revenue Code of 1986, as amended. ARTICLE I DEFINITIONS 1. 1 " Affiliated Employer" means the Employer and any corporation which is a member of a controlled group of corporations ( as defmed in Code Section 414(b) which includes the Employer; any trade or business ( whether or not incorporated) which is under common control as defined in Code Section 414( c) with the Employer, any organization ( whether or

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