CM-10-10-197ROUND ROCK, TEXAS
PURPOSE. PASSION. PROSPERITY.
Item Caption:
City Manager Approval Summary Sheet
Payroll Deduction Agreement
Approval Date: 10/1/2010
Department: Human Resources
Project Manager: Linda Gunther
Item Summary:
Consider authorizing the City Manager to execute a Payroll Deduction Agreement with Liberty National Life
Insurance Company.
Goal 9.0 Ensure plans, policies and procedures are consistent with the vision, intent,
Strategic Plan Relevance: and goals of the strategic plan.
Cost: None
Source of Funds: Please use same source as on RFA
REV. 6/10/10
PAYROLL DEDUCTION AGREEMENT
BETWEEN
LIBERTY NATIONAL LIFE INSURANCE COMPANY
�lKOUNI CA:
AND
COMPLETE NAME OF EMPLOYER (FIRM)
4 (�U�
For the benefit and convenience of its employees, C d C
(hereinafter referred to as the "Employer") agrees to provide r payroll deduction
for insurance by Liberty National Life Insurance Company, Birmingham, Alabama
(hereinafter referred to as "Liberty National Life").
Each employee will authorize payroll deduction in a manner agreeable to the
Employer and Liberty National Life. An employee may stop payroll deduction by
providing appropriate notice to the Employer and Liberty National Life.
Deductions on a schedule to be agreed upon by Liberty National Life and the
Employer will be made from salary paid to employees and such deductions will be
paid promptly by the Employer to Liberty National Life.
The Employer assumes no responsibility for payroll deduction after the termination of
employment of an insured employee, or after an employee stops payroll deduction by
providing appropriate notice.
Either the Employer or Liberty National Life may terminate this Agreement as of any
date by giving at least 30 days written notice to the other prior to such date. After
temination of this Agreement, the payment of premiums shall be entirely and directly
between each employee and Liberty National Life.
Employer
Liberty National Life
C(' C, -E c)u L�
E PLO PRIN NAME LICENSED AGENT PRINT
SIGNATURE
LICENSED AGENT SIG
Jcii, K as, -� �V� GENT NUr lMEA
MBER
0-I.1� `�jl51 1 ()
DATE DATE
R-337, Ed. 05-09
OJr.-tO-! O-1611
AMENDMENT FOR AN EXISTING SECTION 125 PLAN
C P‘V C) -E
e of Franchise)
As of /'5 / ^' , the effective date of this amendment, and notwithstanding
any other provision of this plan, any employee of the employer, and if the plan provides for the
participation of one or more affiliated employers, any employee of such affiliated employers, may
select to have his or her compensation reduced by the amount needed to pay the employee's share
of the cost of coverage, hereinafter referred to as the employee's "premium", under one or more of the
accident or health plans or group term life insurance plans identified below as Qualified Benefit Plans,
and the employer will pay such premiums on the employee's behalf. The employer will also exclude
the amount of the premium from the employee's compensation for FICA and federal income tax
purposes. Where state law permits, the employer will also exclude the amount of the premium from
the employee's compensation for state income tax purposes.
Qualified Benefit Plans shall mean:
• Employer's Group life plan
• Employer's Group health plan
iberty National Group Term Life Insurance
• Liberty National Cancer Insurance
• Liberty National Hospital Intensive Care Insurance
• Liberty National Hospital Income Insurance
• Liberty National Accident Protector Plus Insurance
• Liberty National Accident Plan (ACB) Insurance
• Liberty National Dental Alternative Insurance
• Liberty National Vision plan
An employee shall elect participation in the premium reduction program contained in this amendment
by completing and signing a salary reduction agreement with his or her employer on a form
distributed by the employer. Through such an agreement, the employee agrees to have his or her
compensation reduced by the amount necessary to pay his or her premium for coverage under one or
more of the Qualified Benefit Plans identified above, and the employer agrees to pay such amount on
the employee's behalf.
An employee may elect participation in this premium reduction program only during the period
established by the employer as the election period, during which employees may elect participation in
the plan or revoke or modify existing elections. The election period must end before the beginning of
the plan year for which it will be effective, and must apply on a uniform and nondiscriminatory basis to
all employees.
An election to participate in the premium reduction program shall be effective as of the first day of the
plan year following the election period until the last day of such plan year, and from plan year to plan
year thereafter, unless properly revoked or modified during the election period.
R-3244, Ed. 0409
LNL1101 0409 - Page 2 of 3
After the coverage period has begun, the employee may revoke his or her election and make a new
election (if applicable) only if the revocation and new election arise from and are consistent with a
change in family status. A change in family status means that the employee has had a change in family
circumstances that justifies a change in an election under the premium reduction agreement. Changes in
family status include:
• the marriage or divorce of the employee;
• the death of the employee's spouse or of a dependent of the employees;
• the birth or adoption of a child of the employee;
• the termination or commencement of employment of the employee's spouse;
• the switching from part-time to full-time work, or vice versa, by the employee
or the employee's spouse;
• the taking of an unpaid leave of absence by the employee or the employee's spouse;
• a significant change in the health coverage of the employee or the employee's spouse
attributable to the spouse's employment; or
• any similar change in family circumstances that would be viewed by the Internal Revenue
Service as justifying a change in election under this program.
An employee's participation in the premium reduction program ends:
• on the effective date of a revocation of participation, if no new election is made;
• at the end of an employee's last day of eligible service with the employer;
• upon the employer's termination of the plan; or
• at the employee's death.
Although the premium reduction program is intended to provide certain tax-free benefits to participants,
the employer and the benefits administrator, Liberty National Life Insurance Company, do not guarantee
nontaxability and will in no way be liable for any taxes or other liability incurred by a participant or
anyone claiming through an employee.
Date: ° /l s
R-3244, Ed. 04-09
Signure of Employer:
By:
japlie6 Ylarretek,
Signatures of Affiliated Employers:
By:
Title:
By:
Title:
LNL1101 0409 - Page 3 of 3