CM-04-12-091f„
Request for City Council/City Manager Action
Please submit this form when placing items on the council agenda or when submitting an item to the City Manager for approval.
Department: Human Resources
Contact Person: Teresa Bledsoe
Project Name: FSA Agreement
ContractorNendor Name: Great -West Insurance
Amount: None
Is Funding Required? Yes n No n
Council Agenda Item Yes n No
Submission to City Manager - Yes n No El
(see required signatures below before submission to the City Manager)
Project Manager/Resource: Linda Gunther
Council Meeting Date:
Funding Source:
Assigned Attorney:
City Manager Approval
N/A
J. Kay Gayle
(contract, agreement,amendment,change order, purchase order,etc.)
r i ty i ir: I
CC_ Lit it
i4A t i a
ON)
Agenda Wording:
❑ Initial Construction Contract
❑ Construction Contract Amendment
▪ Change Order
QChange in Quantity
nUnforeseen Circumstances
#_
Initial Professional Services Agreement
❑ Supplemental Professional Svcs. Agr. #
❑ Purchasing/Service Agreement
▪ Purchase Order
Item(s) to be purchased:
Amount
Other (Please clearly identify action on lines below)
Agreement with Great West Life & Annuity Insurance Company for administration of the
Flexible Spending Accounts for medical and dependent care reimbursement.
For Submission to City Manager Only
Project Mgr. Signature:
Dept. Director Signature:
City Attorney. Signature:
City Manager Signature:
Date:
Date:
Date:
Date: 17-1)- 014
-
pproval is required for all items requesting City Manager's approval.
Finance Approval
Winance -Date and Signature:
❑l Purchasing -Date and Signature:
❑ Budget -Date and Signature:
\-(
g/administraton/cmgr-council actionxls 11-1-04
i
DATE:
SUBJECT:
ITEM:
City Manager Approval
Agreement with Great West Life & Annuity Insurance Company for
administration of the Flexible Spending Accounts for medical and
dependent care reimbursement.
Department: Human Resource
Staff Person: Teresa S. Bledsoe
Justification:
This agreement which was adopted October 10, 2002 with Great -West to provide
for independent third -party administration of the Flexible Spending Accounts for
medical and dependent care reimbursement.
Funding: N/A
Cost: N/A
Source of funds: N/A
Outside Resources:
N/A
Background Information:
Great -West provides for independent third -party administration of the City's self-
funded health plan which includes the payment of medical, dental, and vision
claims, administration of the Flexible Spending Accounts for medical and dependent
care reimbursement, monthly and quarterly reports and the coordination of benefits
within the plan document.
Public Comment: N/A
07202FSA Agr(23)-1
FSA ADMINISTRATIVE SERVICES AGREEMENT
BY AND BETWEEN
CITY OF ROUND ROCK
(Herein called the Client)
AND
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
(Herein called the Service Contractor)
Whereas, the Client desires to provide flexible benefits for certain classes of individuals in accordance with a written
plan (hereinafter called "the Plan") as described in an Appendix D;
Whereas, under said Plan the Client will bear all liabilities but desires that the Service Contractor provide certain
services in connection with the administration and operation of the Plan;
Now, therefore, in consideration of the payments to the Service Contractor as provided in the Payment Schedule,
Appendix B, and subject to the terms and conditions contained herein, it is hereby agreed as follows:
Section 1. Services
The Service Contractor will provide the services listed in Appendix A subject to modification as provided herein, for the
administration and operation of the Plan; such services to be coordinated by a representative of the Service Contractor
to assure effective and efficient operation of the Plan.
Section 2. Banking Arrangements
The Client shall establish a separate Benefit Plan Account in a bank as the depository for funds to be used by the
Service Contractor to make payments pursuant to this Agreement and the Plan. The Client shall notify said bank that
they have authorized the Service Contractor, by execution of this Agreement, to issue and accept checks drawn on
such account on behalf of the Client for the purpose of payment of benefits under the Plan. It shall be the Client's
responsibility to maintain funds in this Account sufficient to cover all checks validly issued by the Service Contractor's
authorized employees.
Section 3. Client Reports, Records and Information
The Client hereby agrees to furnish the Service Contractor with certain necessary reports, records, and information in
order to carry out its duties hereunder.
It is mutually agreed that the Service Contractor shall not be responsible for delay in the performance of its duties
under this Agreement or for non-performance hereunder, if such delay or non-performance is caused or contributed to
in whole or in part by the failure of the Client to promptly furnish any required information.
Section 4. Payments to the Service Contractor
For each month in which the Service Contractor performs duties pursuant to this Agreement, the Client shall make
payment to the Service Contractor of amounts due in accordance with the Client's Prompt Payment Policy as stated
below. The amount due shall be determined from the Payment Schedule in Appendix B.
Charges for hourly services will be determined in accordance with the Service Contractor's established time allocation
procedures, and those of other organizations from whom hourly services are purchased.
FSA -1 (7202) (2-01)
07202FSA Agr(23)-2
Printed material, not listed in Appendix A, will be billed for specific items furnished.
The Service Contractor shall have the right to adjust their fees as of the date (a) the Plan is amended to modify
benefits, or (b) its cost of operation is increased solely by virtue of a change in charges to the Service Contractor by a
governmental unit, but such adjustment shall be limited to the amount of the change. The Service Contractor also
shall have the right to adjust their fees on the annual anniversary of this Agreement and annually thereafter by
providing Client notice not less than one hundred -twenty (120) days prior to the effective date of any increase. Client
may, at its sole option, accept the increase, negotiate a lesser increase or terminate this Agreement.
The City's Prompt Payment Policy is as follows:
Payment will be made within thirty (30) days after the City receives the supplies, materials, equipment, or the
day on which the performance of services was completed or the day on which the City receives a correct invoice for
the supplies, materials, equipment, or services, whichever is later. The Service Contractor may charge a late fee (fee
shall not be greater than that which is permitted by Texas law) for payments not made in accordance with this prompt
payment policy, however, this policy does not apply to payments made by the City in the event:
A. there is a bona fide dispute between the City and the Service Contractor concerning the supplies,
materials, or equipment delivered or the services performed that causes the payment to be late; or
B. the terms of a federal contract, grant, regulation, or statute prevent the City from making a timely
payment with Federal Funds; or
C. there is a bona fide dispute between the Service Contractor and a subcontractor or between a
subcontractor and its suppliers concerning supplies, materials, or equipment delivered or the services
performed which causes the payment to be late; or
D. the invoice is not mailed to the City in strict accordance with instructions, if any, on the purchase
order, or the contract or other such contractual agreement.
Section 5. General Provisions
(a) The Service Contractor in performing its duties under this Agreement is acting only as agent of the Client, and
the rights and responsibilities of the parties shall be determined in accordance with the law of agency except
as otherwise herein provided.
(b) The Service Contractor shall use reasonable care and diligence in the exercise of its powers and the
performance of its duties hereunder, but shall not be liable for any mistake of judgment or other action taken in
good faith, or for any loss unless resulting from its gross negligence.
(c) The Service Contractor agrees to indemnify the Client and hold the Client harmless against any and all loss,
damage, and expense, including court costs and attorney's fees, resulting from or arising out of the dishonest,
fraudulent, criminal acts or acts of gross negligence of the Service Contractor's employees, either acting alone
or in collusion with others. The Service Contractor shall maintain Blanket Bond Coverage with a limit in
reasonable proportion in the volume of claims administered.
(d) Except as provided in (c) above, the Client agrees to indemnify the Service Contractor and hold the Service
Contractor harmless against any and all loss, damage, and expense, including court costs and attorney's fees,
resulting from or arising out of claims, demands, or lawsuits brought against the Service Contractor as a result
of or in any way growing out of its administering the Plan, or performing claim reviews, or to recover benefits
under the Plan, including compensatory, punitive, or other damages, and including but not limited to claims for
premium taxes by any governmental unit or other assessments made against the Service Contractor by
governmental units.
07202FSA Agr(23)-3
(g)
The duties to be performed by the Service Contractor under this Agreement may, at its discretion, be
performed directly, wholly or in part, under a contract with an organization of its choosing. Service Contractor
shall advise Client of any and all such organization(s).
The Service Contractor shall consult with the Client or legal counsel designated by the Client in claim matters
that are beyond the ordinary. In the defense of any legal action on a claim for benefits, the Service Contractor
will furnish the Client and his legal counsel all pertinent information regarding the disputed claim, including the
basis for its denial. The defense of any legal action on a claim for benefits shall not be the obligation of the
Service Contractor.
The Service Contractor shall be entitled to rely upon any communication believed by the Service Contractor to
be genuine and to have been signed or presented by the proper party or parties.
The Service Contractor shall not be bound by any notice, direction, requisition, or request unless and until it
shall have been received in writing, or telegraph, by the Service Contractor at its St. Louis, Missouri address,
or at such other address as the Service Contractor specifies for the purposes of this Agreement by notice in
writing addressed to the Client. Notices or communications from the Service Contractor to the Client shall be
addressed to the Client and shall be sent by mail or telegraph to the Client at the same address designated by
the Client, except as otherwise provided in Section 11.
(h) The Service Contractor shall have no power or authority to alter, modify, or waive any terms or conditions of
the Plan, or to waive any breach of any such terms or conditions, or to bind the Client, or to waive any of its
rights, by making any statement or by receiving at any time any notice or information.
FSA -2 (7202) (2-01)
07202FSA Agr(23)-4
(1)
The Service Contractor shall have no power or authority to act for or on behalf of the Client other than as
herein expressly granted, and no other or greater power or authority shall be implied by the grant or denial of
power or authority specifically mentioned herein.
(j) The Service Contractor shall hold as the property of the Client all papers, books, files, correspondence and
records of all kinds which at any time shall come into its possession or under its control relating to the
transactions performed by the Service Contractor for the Client under this Agreement, and shall surrender
them to the Client upon termination of this Agreement or upon prior request, except the Service Contractor
may periodically destroy such material as it would usually destroy in the normal course of business.
(k) The Client shall have the right at all reasonable times to inspect at the claim office of the Service Contractor all
books and documents relating to the administration of the Plan under this Agreement and which relate to such
inspection. Any costs of such inspection shall be borne by the Client.
(1)
Failure by the Client or the Service Contractor to insist upon compliance with any provision of this Agreement
at any given time or under any given set of circumstances shall not operate to waive or modify such provision
or in any manner render it unenforceable, as to any other time or as to any other occurrence, whether the
circumstances, are, or are not, the same and no waiver of any of the terms or conditions of this Agreement
shall be valid or of any force or effect unless contained in a written instrument specifically expressing such
waiver and signed by a person duly authorized to sign such waiver.
No alteration or modification of the terms and conditions of this Agreement shall be valid or of any force or
effect unless in each instance it is contained in a written instrument expressing such alteration or modification
and executed for the Client and the Service Contractor by their officers duly authorized to execute such
alteration or modification.
(m) This Agreement, including any appendices or supplements thereto, shall constitute the entire contract between
the parties and shall govern the rights, liabilities and obligations of the parties hereto, except as it may be
modified in accordance with the provisions of Section 5(1).
(n) Any assignment of this Agreement or of any rights hereunder shall be void and of no force or effect.
(o) It is understood that the Service Contractor performs purely ministerial functions for the Client within a
framework of policies, interpretations, rules, practices and procedures made by the Client. Any review by the
Service Contractor of a claim or of charges declined is made as a service for the Client, who retains the final
responsibility for determining its liability under the Plan.
(p)
Under no circumstances shall the Service Contractor be considered the named fiduciary under the Plan.
Section 6. Controlling Law
This Agreement shall be construed and enforced according to the laws of Texas with venue in Williamson County.
Section 7. Separability
In the event any provision of this Agreement shall be held illegal or invalid for any reason by law or a court of
competent jurisdiction, said illegality or invalidity shall not affect the remaining parts of this Agreement, but it shall be
construed and enforced as if said illegal or invalid provisions had not been included herein either initially, or beyond the
date it is first held to be illegal or invalid if after the effective date of this Agreement, provided the basic purposes
hereof can be effectuated through the remaining valid and legal provisions.
Section 8. Gender and Number
Any reference in the masculine gender herein shall be deemed to also include the feminine gender, unless expressly
provided otherwise. Wherever appropriate, any reference in this instrument in the singular shall include the plural, and
any references in the plural shall include the singular.
FSA -3 (7202) (2-01)
07202FSA Agr(23)-5
Section 9. Counterparts
This Agreement may be executed in any number of counterparts, each of which shall be deemed an original, and said
counterparts shall constitute but one and the same instrument.
Section 10. Currency and Place of Payments
All sums payable to, or payable by, the Service Contractor pursuant to this Agreement shall be payable in the lawful
currency of the United States of America at its St. Louis, Missouri office.
Section 11. Termination of Agreement
(a) Contract Term: This Agreement shall be effective on December 1, 2002, (the "Effective Date"), and
shall continue in force for one year (the "Initial Term") unless terminated earlier pursuant to this Section.
This Agreement shall expire at the end of the Initial Term, subject to the right of the parties to renew the
Agreement as set forth herein, in which case, the Agreement shall remain in force until the expiration of
the period for which the Agreement was renewed (the "Renewal Term"), unless terminated earlier
pursuant to this Section.
(b) Contract Renewal: The Service Contractor shall submit to the Client, not later than one hundred and
twenty (120) days prior to the expiration on the Initial Term and any Renewal Term, the Service
Contractor's proposed terms and conditions for the renewal of the Agreement (the "Renewal
Proposal"). If prior to the expiration of the Agreement the parties do not agree on the terms and
conditions under which the Agreement will be renewed, unless expressly directed by the Client to
discontinue service as of the expiration date, the Service Contractor may elect to continue providing
Services beyond the expiration date in order to facilitate continuity of service for Members. In that case,
this Agreement shall be deemed to have been renewed under the terms and conditions of the Renewal
Proposal as if Client had affirmatively assented to the Renewal Proposal and this Agreement shall be
deemed to have been renewed. Notwithstanding anything above to the contrary, the Service Contractor
shall not be obligated to provide services after the expiration of this Agreement, except to the extent
expressly required to do so under another provision of this Agreement. Once this Agreement is
renewed, whether by express agreement of deemed renewed, this Agreement may be terminated only
as set forth in this Section. In the event Service Contractor does not provide Client with a timely
Renewal Proposal, the current Agreement terms shall apply.
(c) Contract Termination: This Agreement may be terminated for any of the following reason:
If any state or other jurisdiction enacts a law which prohibits the continuance of this
Agreement, the Agreement shall terminate automatically as to such time or jurisdiction on
the effective date of such law or interpretation.
ii. By Client as of any anniversary of the effective date of this Agreement by giving written
notice to the Service Contractor at least thirty (30) days in advance of such date.
By either Party upon failure of the other Party to comply with any material term or
condition of this Agreement.
iv. By Service Contractor as of December 1, 2003, or any anniversary of that date, by giving
written notice to the Client at least one hundred -twenty (120) days in advance of such
date.
Not withstanding the above, this Agreement is a commitment of the Client's current revenues only. It is
understood and agreed that the Client shall have the right to terminate this Agreement at the end of any fiscal
year if the governing body of the Client does not appropriate funds sufficient to pay the contractual charges
as stated herein or attached hereto coming due in the next fiscal year, as determined by the Client's budget
for the fiscal year in question. Such Agreement termination, however, will not in any way adversely affect the
Service Contractor's rights to receive service fees and expenses or other contractual rights becoming due or
accrued under the Agreement prior to the termination.
07202FSA Agr(23)-6
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed by their respective officers
duly authorized to do so, to be effective as of December 1, 2002.
Dated at Round A -i Texas , this k.,50---
(City) (State) (Date)
day of R%PCF(YlI7fX 20 ()y
(Month) (Year)
CITY OF ROUND ROCK
By:
(Signature of Authorized of Authorized Representative)
t
, C
y ,i M416 fx"
(Offici I Title)
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
By:
�GCN� j/ u
(Signature of Authorized Representative)
Assistant Group Secretary
(Official Title)
June 16, 2004
(Date)
FSA -4 (7202) (2-01)
07202FSA Agr(23)-7
APPENDIX A
SERVICES TO BE PROVIDED BY THE SERVICE CONTRACTOR
To be attached to and made a part of the Agreement by and between
CITY OF ROUND ROCK
AND
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
The services to be performed by the Service Contractor are as set forth below:
A. CLAIMS ADMINISTRATION includes one of the following as selected below:
1. STANDARD MAIL: The Client mails reimbursement requests to the Service Contractor who
processes claims and mails reimbursement checks to the Client.
2. DIRECT MAIL: The Client mails reimbursement requests to the Service Contractor who processes
claims and mails reimbursement checks directly to beneficiaries.
3. DIRECT CLAIM: Beneficiaries mail reimbursement requests to the Service Contractor who processes
claims and mails reimbursement checks directly to the beneficiaries.
4. MODIFIED DIRECT CLAIM: Beneficiaries mail reimbursement requests to the Service Contractor
who processes claims and mails reimbursement checks to the Client.
The Client elected and the Service Contractor agreed to provide the above described claims administrative
services as indicated below:
3 (enter 1, 2, 3, or 4) for Health Care Reimbursement Account;
3 (enter 1, 2, 3, or 4) for Dependent Care Reimbursement Account.
B. CENTRALIZED HEALTH CARE REIMBURSEMENT ACCOUNT (AND DEPENDENT CARE
REIMBURSEMENT ACCOUNT) ADMINISTRATION as described in Appendix C.
FSA -A-1 (7202) (2-01)
07202FSA Agr(23)-8
APPENDIX B
PAYMENT SCHEDULE
To be attached to and made a part of the Agreement by and between
CITY OF ROUND ROCK
AND
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
The client shall make payments to the Service Contractor by the tenth day of each month following the month in which
the Service Contractor performs duties pursuant to this Agreement. The amount due will be determined as follows:
(A) Services Provided: Amount Due
Initial Set -Up Fee $1,800 (one time fee)
Renewal Fee $1,050 per year
Health Care Account Administration $5.65 per participant
and/or Dependent Care Account Administration per month
(including Claims Administration)
Note: a total monthly fee of $5.65 per participant will be
charged for these services regardless if the participant has
enrolled in only one or both services.
Dependent Care Account Administration $5.65 per participant
(including Claims Administration) per month
(B) The cost of customized or bulk printing will be billed as charged to the Service Contractor including
Summary Plan Descriptions and other documents not specifically listed in Appendix A; and
(C) The cost of any mass mailings to plan participants will be billed separately.
FSA -B-1 (7202) (2-01)
07202FSA Agr(23)-9
APPENDIX C -1
(1) HEALTH CARE REIMBURSEMENT ACCOUNT ADMINISTRATION
To be attached to and made a part of the Agreement by and between
CITY OF ROUND ROCK
AND
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
The Client and Service Contractor shall have the following responsibilities in connection with the administration of
health care reimbursement accounts created by Plan beneficiaries according to the terms of the Plan:
1. On or before the effective date of the Agreement and January 1 thereafter, while the Agreement is in effect,
the Client shall notify the Service Contractor in writing of those Plan beneficiaries who will participate in the
Plan's health care reimbursement account during the following calendar year. This notice shall include the
name, address, and Social Security number of each such beneficiary, and the amount each beneficiary has
elected to contribute to his or her account during the calendar year.
2. A Plan beneficiary who has established a health care reimbursement account may make claim for
reimbursement using only forms which have been approved by the Service Contractor. Such form shall
include the Plan beneficiary's name and Social Security number, the name of the qualifying person on whose
behalf the claimed expense was incurred, and a description of the expense, including the name of provider to
whom the expense was paid and the date(s) it was incurred and the amount. Such form shall also include a
certification that the amount claimed is not reimbursable under any of the Plan beneficiary's or his spouse's or
dependent's health care plan and is qualified as a health care expense under the provisions of the Internal
Revenue Code of 1986 applicable at the time the expense was incurred. The Service Contractor shall have
no duty to process any claim for reimbursement which in its sole opinion doesn't meet the requirements of this
paragraph 2.
3. The Service Contractor shall accept for processing and payment or denial all claims from Plan beneficiaries
for reimbursement of health care expenses. The Service Contractor shall investigate the validity of each claim
and shall compute the amount of reimbursement due, if any, on each such claim. The Service Contractor will
reimburse a Plan beneficiary the amount of each valid claim up to the balance of the maximum amount
remaining in the beneficiary's health care reimbursement account pursuant to his then effective election under
the Plan. Each reimbursement amount will reduce the maximum amount of the beneficiary's health care
reimbursement account available for expenses incurred during the remainder of the same calendar year.
4. The Service Contractor shall refer all contested or doubtful claims to the Client for its determination of liability
and instruction to the Service Contractor.
5. The Service Contractor shall pay all claims for health care reimbursement from an account established by the
Client and to which the Client shall from time to time deposit those amounts which Plan beneficiaries have
elected to contribute to their health care reimbursement accounts. Clients shall accompany each such deposit
with a report in a format acceptable to the Service Contractor showing the name and Social Security number
of each beneficiary on whose behalf contributions are deposited, and the contribution amount attributable to
each beneficiary.
6. On the fifth working day of each month the Service Contractor will notify the Client of the total amount of health
reimbursement claims it approved for payment during the previous month.
FSA -C-1 (7202) (2-01)
07202FSA Agr(23)-10
7. Within 30 days after the end of each calendar quarter the Service Contractor shall distribute to each Plan
beneficiary who has established a health care reimbursement account a statement showing year-to-date
contributions to his or her account, reimbursements made, and the account balance as of the end of the
quarter.
8. Within 30 days after the fifth day of each month the Service Contractor shall provide the Client with an
accounting for the previous calendar month showing for each Plan beneficiary who has established a health
care reimbursement account the amount contributed, claims paid, and the account balance as of the end of
such month.
9. The Service Contractor shall perform the services described in this Appendix C in an administrative capacity
only, and shall have no authority nor responsibility to determine whether any amount claimed as a health care
expense qualifies for reimbursement under the Internal Revenue Code of 1986. The Service Contractor shall
have no obligation to the Client, nor to any Plan beneficiary, nor to any other person for any tax, interest,
penalty, or other amount which might be assessed as a result of any reimbursement the Service Contractor
makes under the Plan.
FSA -C-2 (7202) (2-01)
07202FSA Agr(23)-11
APPENDIX C-2
(2) DEPENDENT CARE REIMBURSEMENT ACCOUNT ADMINISTRATION
To be attached to and made a part of the Agreement by and between
CITY OF ROUND ROCK
AND
GREAT -WEST LIFE & ANNUITY INSURANCE COMPANY
The Client and Service Contractor shall have the following responsibilities in connection with the administration of
dependent care reimbursement accounts created by Plan beneficiaries according to the terms of the Plan:
1. On or before the effective date of the Agreement and December 1 thereafter, while the Agreement is in effect,
the Client shall notify the Service Contractor in writing of those Plan beneficiaries who will participate in the
Plan's dependent care reimbursement account during the following calendar year. This notice shall include
the name, address, and Social Security number of each such beneficiary, and the amount each beneficiary
has elected to contribute to his or her account during the calendar year.
2. A Plan beneficiary who has established a dependent care reimbursement account may make claim for
reimbursement using only forms which have been approved by the Service Contractor. Such form shall
include the Plan beneficiary's name and Social Security number, the name of the dependent on whose behalf
the claimed expense was incurred, and a description of the expense, including the name and Social Security
or federal tax identification number of the provider to whom the expense was paid, the date(s) it was incurred
and the amount. Such form shall also include a certification that the amount claimed qualifies as a dependent
care expense under the provisions of the Internal Revenue Code of 1986 applicable at the time the expense
was incurred. The Service Contractor shall have no duty to process any claim for reimbursement which in its
sole opinion doesn't meet the requirements of this paragraph 2.
3. The Service Contractor shall accept for processing and payment or denial all claims from Plan beneficiaries
for reimbursement of dependent care expenses. The Service Contractor shall investigate the validity of each
claim and shall compute the amount of reimbursement due, if any, on each such claim. The Service
Contractor will reimburse a Plan beneficiary the amount of each valid claim, but such reimbursement shall be
limited to the amount then on deposit in the beneficiary's dependent care reimbursement account. If the
amount of reimbursement due exceeds a beneficiary's funds then on deposit, the Service Contractor will
reimburse the beneficiary the total of the funds on deposit and pend the balance of reimbursement due. Such
balance shall be paid out of the beneficiary's subsequent contributions, if any, to his or her dependent care
reimbursement account during the calendar year in which the claim was incurred.
4. The Service Contractor shall refer all contested or doubtful claims to the Client for its determination of liability
and instruction to the Service Contractor.
5. The Service Contractor shall pay all claims for dependent care reimbursement from an account established by
the Client and to which the Client shall from time to time deposit those amounts which Plan beneficiaries have
elected to contribute to their dependent care reimbursement accounts. Client shall accompany each such
deposit with a report in a format acceptable to the Service Contractor showing the name and Social Security
number of each beneficiary on whose behalf contributions are deposited, and the contribution amount
attributable to each beneficiary.
6. On the fifth working day of each month the Service Contractor will notify the Client of the total amount of
dependent reimbursement claims it approved for payment during the previous month.
FSA -C-3 (7202) (2-01)
07202FSA Agr(23)-12
7. Within 30 days after the end of each calendar quarter the Service Contractor shall distribute to each Plan
beneficiary who has established a dependent care reimbursement account a statement showing year-to-date
contributions to his or her account, reimbursements made and claim amounts pended, and the account
balance at the end of the quarter.
8. Within 30 days after the fifth day of each month the Service Contractor shall provide the Client with an
accounting for the previous calendar month showing for each Plan beneficiary who has established a
dependent care reimbursement account the amount contributed, claims paid, amounts pended, and the
account balance as of the end of such month.
9. The Service Contractor shall perform the services described in this Appendix C in an administrative capacity
only, and shall have no authority nor responsibility to determine whether any amount claimed as a child care
expense qualifies for reimbursement under the Internal Revenue Code of 1986. The Service Contractor shall
have no obligation to the Client, nor to any Plan beneficiary, nor to any other person for any tax, interest,
penalty, or other amount which might be assessed as a result of any reimbursement the Service Contractor
makes under the Plan.
FSA -C-4 (7202) (2-01)
07202FSA Agr(23)-13
APPENDIX D
PLAN DOCUMENT