HomeMy WebLinkAboutRESOLUTION NO. 2024-17RESOLUTION NO. 2024-17
RESOLUTION UPDATING THE CITY OF FAIRFAX'S 125 PLAN
WHEREAS, the City Council of Fairfax, Iowa wishes to provide its employees
with the opportunity to obtain benefits; and
WHEREAS, the City Council does currently have a benefit package that includes
health insurance, life insurance, shoi�t-tei-�n disability, and AD&D insurance, which the City
of Fairfax cunently pays the premium cost far qualifyiilg elnployees and inakes the health
insurance available to qualifying employees' families at the employee's cost; and
WHEREAS, the City of Council desires to offer a wider variety of benefit
programs to the employees at the elnployee's cost; and
WHEREAS, AFLAC, Colonial Life, and Globe Life Liberty National have all
submitted the paperwork participate in Fairfax's Flex One 125 Cafetei•ia Plan that will
allow foi• preiniums to be pre-tax for all qualifying benefit plai7s except the life insurance
coverage and any disability coverage that may be chosen by an employee.
NOW, THEREFORE, BE IT RESOLVED, by the City Council of the City of
Fairfax, Iowa, that the City of Fairfax does hereby revise their ,Flex One 125 Cafetei•ia Plan
to enter into the Payroll Account Acknowledgement Agreements with AFLAC, Colonial
Life, and Globe Life Liberty National to participate in this plan.
BE IT FURTHER RESOLVED, by the Fairfax City Council that the City of
Fairfax hereby agrees to allow AFLAC, Colonial Life, and Globe Life Liberty National to
make a presentation to all einployees about their benefit programs.
BE IT FURTHER RESOLVED, by the Fairfax City Council of the City of
Fairfax, Iowa, that the Mayor and City Clerk are hereby authar�ized and directed to execute
this resolution.
Passed and approved this 13t�' day of February, 2024.
AYES: Nurre, Wozniak, Volk, and Wainwright
NAYS: None
ABSENT: Daly
ATTEST:
nthia Stimson, City Clerk/'T'reasurer
,-�
�,�; C�.--�.�.�
Jo Ann Beer, Mayor
City of Fairfax �
Section 125 Plan
Plan Document
Amended and Restated as of February 1, 2024, unless otherwise noted
Disclaimei: This document is made available by MineralT"' as a service to its clie�lis. This document l�as been
prep�t-ed for Muier�lT"' by Barrow Weatherhead Lent LLP ('BWL") and is ultended to be used by a comp�ny
sponsorll�g a Section 125 Premium Oi11y Plan. While BWL from time-to-time updates this ir�odel fonn document
for MineralT"', BWL specifically disclaims any i•esponsibility to (1) enslli-e this sample docuinent is appropi-iate for
any MineralT" client's use or (2) provide updates to reflect changes iu applicable law directly to any MineralTM clienC
that does not main�ain a client relationsl�ip with BWL. Clients who choose to use this docuinent sl�ould consult with
their own counsel to adapt this foi•m to tl�eii- plan terms and are responsible for ensucing that tl�is document is
consistent tivith any carrier docu»�ents and with l�ow the plan is bein� administei-ed by any Chird party administrators.
This document is not intended, and should t�ot be viewed, as legal guidance or advice. Specific questions about the
tax or legal implications of employer plans sl�olild be referred to qualified counsel. This document is »ot and should
not be deemed to be n� any way made available as an indlicement to establish or maintan� a business relationship
with BWL.
`Table of Contents
Tablc of Coi�tents
f1RTICLE I
Inu�oduction
ARTICLE IT
P articipation
ARTICLE Ill
Optional Benefits
ARTICLE IV
Administration
ARTICLL V
Amendment and Tei-�nu�ation
ARTICLE V(
Claims Provisions
AR'I'1CLE VTI
Miscellaneous
ARTICLE VIll
Definitions
APPENDIX A
PARTICIPATING EMPLOYERS
10
10
12
12
City of Fairfaa
Section 125 plan
ARTICLE I
]ntroduction
1.1 Purposc of Plau. Thc pu�posc of tl�is Plan is to }�iovide eligible employees of City of Faii-fax a cl�oice betwee» casli
and benefits under o�ie or more Qualified Beuefit Plans.
1.2 Plan Status and Establisl�ment. 7-his Plan is intended to satisfy tl�e requirements of Section 125 of the Internal
Revenlie Code of 1986, as amended from time� to time (Che "Code"). The Plan was established effect'ive Februaiy l,
2023, and amended and restated effective February l, 2024.
ARTICLE II
Participation
2.l Commencement of Participation. Each Employee will be e(igible to participate in the Plan on the fi�st day on which
I�e or she meets the eligibility requireine»ts of any Qualitied Bene�t Plan. An Em}�loyee will become a Participant upon
inaku�g an election in �ccoi-dance wi�l� the provisions of SEction 3.3.
2.2 Cessatio�� of Partici��ation. A Participant will cease to be a Participant in this Plan as of tl�e earlier of (i) tl�e date on
which this Plan terminates or (ii) the date on which l�e or sl�e dies, terminates employment with tl�e Plan Sponsor, or
ceases to be ai� Employee eli�ible to participate undei- Section 2.l .
2.3 Reinstateinent of Former Partici}�ant. A former Participant will aganl become a Participaiit if and when he or sl�e
fn-st meets the eligibility requirements of Section 2.1.
2.4 Par-tic�ation Durin� Uniformed Services Leave of Absence; Similar State Leaves. Any Employee who is absent
from work due to a pei-iod of duty in the Unifoin�ed Seivices; or leave under a similar or ec�uivalent, applicable state
fan�ily and medical leave law that re�uires health benefits continuation, will have the right to continue pai-ticipation in
any Qual��ed Benefit Plan. The Employee's right to manrtain coverage while on a leave of absence is conditioued on
the Employee's continuv�g to have an employment relationship with the Plan Sponsor and inalcing the requu�ed
conh�ibutions as p3-ovided in Section 3.9, as applieable.
ART7CLE III
Optional Benefits
3.1 Contributions. A Participant may elect under this Plan to receive l�is or her full Compensation foi- a�ry Plan Year in
cash or to have a portion of his or hei- Compensation applied by tl�e Plan Sponsor to the payment of Employee
P�-ovided Premiums, as the case may be, tmder any one or more Qualitied Benefit Plan(s).
3.2 Receipt of Benefits otl�er than Cash. While the election to receive benefits under one or more Qualifed Beneft
Plans ni lieu of casl� is made wlder this Plan, benefits will be provided under the applicable Qualified Benefit Plan. The
options available tmder eacl� such plan, the i-equiremenCs for participating in such options, the ainount of premiums,
deductibles and co-payments (if any), the amount, timing and conditions for the receipt of benefits and all othei- te�7ns
ai�d conditions of eligibility, coverage and benefits iuldet• suc}� options are set fortl� in the Qnalified Benefit Plans. Any
claim wl�icl� ai-ises tiinder a Qualified Benefit Plan will be stiibject to revicw tmdej- tl�e Qualified Benetit Plan and ��ot
under this Plan.
3.3 Election of Benefits.
(a) A Pai-ticipant may file a written election or elections with the Administt•ator (on forms pi-ovided by tl�e Plan
Sponsor) to receive his or her fiill Compensation in cash or to l�ave such Compensation reduced by Cl�e amount of
the Employee Provided Piemiums under any applicable Qualified Benefit Plan. Sti�ch election must be made not
later than (i) the �r-st day of the coverage period to which such election t-elates (u1 the case of an e�stn�g
Employee) or (u) the first day of the first pay period to which such election relates (u� the case of a newly eligible
Einployee), or sucl� earliei- tnne as determined by the Adlninistrator. If a Participant elects to l�ave conti-ibutions
made to a Qualitied Bei�efit Plan, such amounts will be contributed to a Qualified Benef7t Plan by tl�e Plan
Page 3
Sponsor on behalf of such Participant ���itl�in a reasonablc timc, but i�� no case later than nincty (90) days
follo��ing thc date on ���Ilich the sa���e would have otherwise been paid to such Participai�t.
(bj If a Partici}�ant does ❑ot return a coinpleted election form to tl�e Administrator on or before the date specitied
in Section 3.3(a), he or she �vill be deemed to have elecCed to receive the full amount of l�is or her Compensation
in cash.
3.4 In-evocability of Election bv the Partici��ant.
(a) Ai�y election made under the Plan sl�all be irr-evocable by the Participant during the Plan Year except as
other-wise provided in (b) through (1) below.
(b) Witl� respect� to any Qualified Benefit P]a�1, a Participant may i•evolce an election i�� wl-itinb for the balai�ce of
the Plan Year and, if desired, tile a»ew election in writing if, under the facts and circumstances, (i) a cl�angc in
status occurs, and (ii) the i-equested revocation a»d new election satisfy Che consistency i-e�uirements in Section
3.5 below. For this purpose, a change in stat�ts includes the following events:
(i) Legal Mar-ital Stariis. An event tl�at cl�anges a Participant's legal marital stah�s, including marriage, death
of spouse, divorce, legal separation or� annulment.
(ii) Number of Depei�dents. An event that cl�anges a Participant's number of Depende»ts who may be
eli�ible for coverage under a Qualified Be��e�t Plan, iucluding birth, death, adoption or place�nent for
adoption.
(ui) Employment Status. An event that changes the employment status of the Participant or the
Participant's spouse or Dependent, including termination or commencement of employment, a strikc or
locicout, a cornmencemcut oi retw�i from an unpaid leave of absence, and a change in worksite, as well as
any other change in tl�e individual's employment status that results in the individual becon�ing (or ceasing to
be) eligible under a benefit plan of his or her employer.
(iv) Rec�liire���ents for Unmarr-ied De}�endents. An event t}�at causes a Dependent to satisfy or cease to
satisfy the r-equirements 1'or coverage on account of attainment of age, shtdent status, or any similac
cii•cu»�stance.
(v) Residence. A change i�� tl�e place of residence of the Participant, his or l�er spouse or Dependent.
(vi) Other. Such other events tl�at the Administrator determi��es will permit tl�e revocation of an election
(and, if applicable, the filing of a new election) dm�ing a Plan Year lmder regulations and iti�lings of the
Internal Revenue Setvice.
(c) In Cl�e case of coverage �mder a gt-oup health plan that is a Qualified Benefit Plan, a Participant roay revolce an
election in writing for the balance of the Plan Year and file a new e]ecYion in writing that corresponds with tl�e
special enrollment rights provided in Code Section 9801(�, whether or not tl�e cl�ange i» election is pern�itted
under Section 3.4(b).
(d) In the case of a judgmei�t, decree or order resulting from a divorce, legal separation, annulment, or change in
legal custody (inchiding a qualified �nedical child snpport order) tl�at reqiiires accident or I�ealth coverage foi• a
Participant's cl�ild oi- for a foster child who is a Dependent of the Pai•ticipant, a ParticipanC may cl�ange his or- her
elecCion (i) in order to provide coverage for the child ln�der a group health plau that is a Qualified Benefit Plan if
the order so requues, or (ii) n� order to cancel health coverage under a g-oup health plan tl�at is a Qualii:ied Benefit
Plan for the Participant's cl�ild if sucl� order requues the Participant's spouse or fonner s}�ouse or anotl�er
iudividual to provide coverage for the child and that coverage is, in fact, provided.
(e) In the case of covera�e under a group l�ealth plan that is a Qualified Benefit Plan, a Participant may revoke an
election for the balance of the Plan Year and file a new election in order to cancel or reduce such medical
coverage for the P�rticipant or any covered Dependent of the Pat-ticipant to the extent tl�at the Participant or
Dependent becomes entitled to coverage undei- .Part A or Part B of Title XVIlI of the Social Secui-ity Act
(Medicare) or Title XIX of the Social Security Act (Medicaid), other than coveragc consisting solely of benefits
nnder Section ,1928 of tl�e Social Securiry Act (the program for distribution of pediah-ic vaceu�es). In addition, if
the Participant or any eli� ble Dependent wl�o lias been entitled to Medicare or Medicaid loses eligibility foT- sucl�
cove�-age, the Participant may tile a new election for tl�e balance of tl�e Plan Year to commence or inc��ease
coverage under another grolip healtl� plan tl�at is a Qualified Benefit Plan.
Page 4
(� 1f the Participants' share o1'the cost of covcrage tu�dcr a Qt�alitied Benefit Plan signiticantly increases or
signiticantly decrcases during the Plan Ycar, a Participai�t may make a corresponding change in election ui�der the
Plan for the balancc of tl�e Plan Ye�r, whicl� will i��elude (bllt not be limitcd to) thc follo���ing:
(i) for a si���if7c�nt cost incrcase, Particip�nts electiug sucl� coverage for tl�e Plan Year may revol<e their
election v�d eitl�cr elect a similar coverage tmcier v�othcr Qualitied Benefit Plan for the balance of thc Plan
Yeat-, or clrop sucl� coverage if theie is i�o similar covei-age wider a Qualified Benefit Plan; or
(ii) for a si«uiticant cost decrease, Participants may elect to commence par•ticipation under cer�tain options
under a Qualified Benefit Plan with the si��r�ificant cost decrease and may �nake corresponding electioi�
changes regarding similar covei-age, for the balance of tl�e Plan Year.
Despite any otl�er contra�y provision of tl�e Plan, fo�- any nlsigalificant changes u� the costs of ai7y Qualified
Benefit Plans, the Administrator shall automatically c}�ange Participants' elections to accotli�t for sucl� changes in
cost.
(g) If the Participant or his or her spouse or Dependents experience a significant clirtailment in coverage w�der a
Qualified Benetit Plan dtiu�ing the Plan Year, the Participa��t may malce a cori-espondiug cl�ange in election under
the Plan fol- tl�e balance of tl�e Plan Year as follows:
(i) for a significant cl�rtailment that is not a loss of coverage, the Participant electulg such coverage for the
Pl�u� Year may i-evoke l�is or- her election and elect a snnilar coverage under another Qualified Benefit Plan
for the balance of the Plan Year; o�-
(ii) for a significant ctzrtailme�lt that is (or is deemed by the Administrator to be) a loss of coverage, the
Participant electing such coverage foi- tl�e Plan Year may revoke his or her electio�� and either elect similar-
coverage under another Qualified Benefit Plan for the balance of tl�e Plan Yeaf•, or drop sucl� coverage if
thei-e is no similar coverage under a Qualified Benefit Plan.
(h) If during the Plan Year a uew Qualified Benefit Plan, or option und�r a Qualified Benefit Plan, becomes
available, or an e�stu�g Qualified Beneflt Plan, or option under a Qualified Benefit Plan, is si�iificantly v�iproved,
Participants may elect the new or sibnificantly improved coverage, and may make cor7�esponding election changes
regarding similar coverage, for the balance of tl�e Plan Year.
(i) If a Participant's spouse or Dependent makes ai� election change under a plan maintai�ied by his or her
employei-, the Adnzinisti-ator may perinit the Participant to revolce an election under this Plan and malce a new
election for the balance of tl�e Plan Year that is on account of and coiresponds with the election change made by
the Participant's s�ouse or Dependent, if:
(i) the election change made by tl�e Participant's spouse or Dependent under his or her employer's plan
saCisfies the regulations and mlings m�dei- Code Section 725; or
(ii) the period of cover-age under tl�e plan maintained by the employer of the Participant's spouse or
Dependent does not correspond with the Plan Yeat• of this Plan.
(j) If a Participant ot- l�is oi- }�ei- spouse or Dependent loses group health coverage sponsoi-ed by a govennnental or
educational institution, the Participant may elect health coverage under one or more Qualified Beneiit Plan(s) for
the balance of tl�e Plan Year for t}�e Participant, his or her spouse or Dependent.
(k) If a Participant and/ol- any of a F'articipant's i•elated u�dividuals em�olls i�1 or intends to ent�oll in Marketplace
coverage duruig tlie Marl<ctplace's aunual open enrollment period or during a special enrollment pei-iod, the
Administi-ator Inay pennit tl�e Participant to revolce an election under the Plan that is on accotmt of and
corresponds with:
(i) the Participant's
(n) the Pa1-ticipant's related i��dividual or related individuals', or
(ni) both the Participant's and the Participant's related individuals'
enrollment in a Marketplace plan effective immediately following the revocation. If the Participai�t does not enroll
u1 Mv-ketplace coverage, the Participant ml�st elect self-only coverage (or family coverage ulcluding one or �nore
already-covei-ed related individuals) unde�- tl�e giaup llealth plan. Coverage may only be terminated for those
covered individuals wl�o are enrollinb or u�tend to enroll u� Marketplace coverage diu-n�g open cnrollment or
-- - — �ge 5 �--- -- - �-- -
pursua»t to a Mai1<ctplacc sE�ccial enrolin�ent period.
Tl�e Administrator �nay rely on the i-easonable i-e}�i-csentation of the Pai-ticipant tl�at tl�e Participar�t and/or
the Participant's related individual or related individuals have enrolled or intend to enroll in a Marl<etplace plan
that is effective immediately �followii�g the revocation. No change is permitted with regard to i�o��-health benctits
availablc under thc Plan.
(I) If a Participant wl�o �v�as i-easonably cxpected to avei-age 30 l�ow-s of seivice o1- inore per ���eelc expel�ie�iccs a»
employinent status change such tl�at he or sl�e is i-easonably expected to average less than 30 l�ou1-s of service per
week may prospectively r-evolce his or her election under the Plan, provided tl�at the Participant certities to the
Adn�inistrator that he or she and any related individuals whose coverage is being revoked have enrolled or intend
to enroll in another plan providing "i��inimurn essential coverage" (as detined linder the Affordable Care /�ct) for
cover-age that is effective no later than the fiist day of the second month following the mo��th thaC includes tl�e
date the original coverlge is revolced. I�o cl�ange is pe1-mitted with regard to non-health benefits avail�ble under
the Plan.
(m) Any application for a revocation and new electioi� under this Section 3.4 must be »�ade within 30 days
following the date of the actual event, or within 60 days of the occurrence of one of the followir�g events: (i) a
ParCicipant's or Dependent's coverage under a Medicaid plan or state children's health insw�ai�ce program is
terminated as a result of loss of eligibility for sucl� coverage; or- (ii) the Pat-ticipant or Dependent becomes eligible
for a state premium �ssistancc subsidy fi-om a Medicaid plan or throu�h a state children's health instu•ance
pro�-a�n with respect to coverage under tlle ;roup healtl� plai�, and shall be effective at such time as tl�e
Adtninistrator shall pi-esci-ibe.
3.5 Consistency Rules. A Participai�t's requested revocation and new election under Section 3.4(b) will be consistent
with a change ni stahis if tl�e election change is on account of and corresponds with a change ui status that affects the
eligibility foi- covei-age under a Qualified Benefit Plan or under a plan mauitanied by the employer of the Participant's
spouse or Dependent. A change in statzls tl�at af%cts the eligibiliry lmder ali employer's plau shall ulclude a changc in
status that i•csults in an u7crease or decrease v� the numbei- of a Participant's family meinbers or Dependents who may
benefit fi-om coverage under tl�e plan.
3.6 Auto���atic Termination of Election. Electio»s made or deemed to be made undet• Section 3.3 will alltomatically
termulate on the date on which the Participant (i) termii�ates employment with the Plan Sponsor or (ii) elects mlder
Section 3.3 or 3.4 to receive casl� in lieu of benefits under the Qualified Benefit Plans, although coverage or benefits
mider any group health plan that is a Qualificd Benefit Plan may contuiue if and to the extent provided by such plan or
as required by law. Despite any otl�er contra�y provision of Che Plan, if a Participant's einployment with the Plan
Sponsor Cerminates and tl�e Participant retiu-i�s to employment witl� the Plan Sponsor witl�in thirty (30) days of such
termination and witl�in the same Plan Year of the Participant's date of termination, tl�en the Participant's pre-
termination elections under tl�e Plan will be automatically reiustated, anci no clection changes shall be permitted unless
otherwise spccified by Section 3.4.
3.7 Changes bv Adminisri-ator. If the Adzninistr-ator detei7uines, at any time, that the Plan may fail to satisfy any
nondiscrimination 7-equirements imposed by the Code with respect to benefits provided to higl�ly compensated
individuals (as defined in Code Section l05(h)), highly compensated employees (as defined in Code Section 4l4(q)) or-
key employees (as defined in Code Section 416(i)(] )), the Administrator will take such acCion as the AdminisU-atoi-
deems appropriate, under n�les tiniformly applicable to similarly situated Participants, to assure compliance witl� such
requirements. Such action may include, without limitation, a modification of electioiis by such highly compe�lsated
individuals, highly compensated employees or key employees with oi- withotrt their consent.
3.8 Maximum Conh-ibutions. The maximui�� amount of the cor�tributions under this Plan for any Participant i�1 any Plai�
Year will be tl�e sum of tl�e Employee Provided Premiui��s, as amended fi-on� time to time, of tl�e most expensive
benefits available to the Participant m�der each Qualificd Benefit Plan for such Plan Year.
3.9 Premium Payments b��lovecs of Unifoi-�ned Scrvices Leave of Absence� Similar State Leaves. Any Employee
who elects to �naintain covel•age under S�ction 2.4 while absent from work for more than 31 days for dury in the
Unifo�-med Services must continue to make any required conU-ibutions specified in Section 3.3. Dtlring sucl� absence,
an Employee may cl�oose to make sucl� contriblitions by (i) remitting payment to the Plan Sponsor on oc before each
pay period for wl�ich the contributions would l�ave been deducted fi-om the Employee's paycheck if leave had not been
taken, provided that any delinc�uent payments milst be made witl�in 30 days of their due date, or (ii) at the Employee's
Page 6
written elcction (o�� forms fiiri�ished by and delivercd to the Administrator not less than 30 days prior to prepaymci�t),
prepaying the amounts that will bcco���c due during such leavc out of one or more of the Employee's paychecl<s
preceding sl�ch Icave. Tl�e Plan Sponsor, in its sole discrction, may agree witl� the Employee to fund tl�e Lmployee's
rec�uired contributions undcr Scctioi� 3.3 durii�g thc leave of absence, as long as the Employee agrees (on fonns
furnished by aud delivcrcd to tl�e Administrator not less than 30 days prior to commencement of such leave of absence)
to commence re�nitting payme»t to tl�e Plan Sp���soi- upo�l �}�e Lm}�loyee's rettu-n to active employi7�ent with tl�e Plan
Sponsor follo��ing the leave of absence of all amotults paid by the Plan Sponsor on the Employee's behalf to maintain
coverage Linder Section 2.4; provided, however, if a�� Employee 1'ails to rettu�n to active employment with the Plan
Sponsor following the leave of absence, then the Employee shall reimburse the Plan Sponsor for sucl� advances made
on the Tn�ployee's bchalf within thirry (30) days following the Plai� Sponsor's writCen deinand for such rei���burseinent.
D�spite the foregoing, an Employec who is absent fi-om worlc for any paid leave of absence must continue any and all
benefits elected t�ndei- tl�is Plan (unless the same is prol�ibited by any n�surance policy provision requi�-ing an insured to
be actively at wo3-k), and Employee conti-ibutions for tl�ose beneiits tl�at tlle Employee chooses to continue while on tl�e
leave of absence will conti��ue to be dedtac�ed fi-om the Employee's paychcck ni sucl� absence.
ARTiCLE iV
Administration
4.1 Plan Administration. The administt-ation of the Plan will be under the supeivision of the Administrator�. It will be a
duty of the Administrator to ensure tl�at the Plan is carried out, i�l accordance with its terms and n� a nondiscrimivaroiy
manner, for tl�e exclusive benefit of Participai�ts and their beneficiaries. Tl�e Administrator will have the power to
ad»�inister the Plan, subject to applicable requirements of law. The Administrator's powers include, but are not limited
to, discretiona�y autl�ority:
(a) to make and enforce such rules and re�ilations as the Adininistratoi- deems necessaiy or appropriate for tl�e
efficient administration of the Plan:.
(b) to inCerpret the P lan (such inteipretation will be �nal, binding and conclusive with respect to all claims arising
under this Plan);
(c) to decide all questions coucemiil� the eligibiliry o�F any person to participate in and to receive benefits under the
Plan, and to ma]<e al] factual determinations;
(d) to provide Employees witl� a i-easonable and tnnely notification of benefit options available under the Plan;
(e) to autl�orize the payme��t of benetits, which will be paid only if the Administrator deeides in its sole discretion
that the Participant or applicant is entitled to the�r�; and
(� to appoii7t such agents, couusel, accountants, co�7sultants, and actual-ies as may bc requued to assist ui
admi�listeru�g the Plan.
4.2 Payment of Ex}�ei�ses. Administrative expe��ses will be �aid by the Plan Sponsor. The Administrator may impose
t-easonable conditions foi- payments, provided that stiich conditious do not discrimi»ate in favor of Participants wl�o ai•e
highly compensated employees or key employees.
4.3 Examination of Recoi•ds. Tl�e Administrator will mal<e available to eacl� Participant l�is or hei- records under this
Plan for examinaCion at reasonable times d�n-ing nor-mal btilsiness l�ours.
4.4 Reliance on Tables Etc. In admnlisteriug the Plan, the Administrator will be entitled to rely conchlsively on all
tables, valuations, certificates, opulions and reports fiarnished by, or ii1 accordance with the u�sh-uctions of, any insurer,
or by accountants, counsel or other e�perts employed or en�aged by the Adminish�ator.
4.5 Indemnification of Administrator. The Plan Sponsor agrees to indcmnify, l�old harmless and defend any Em}�loyee
servuig as the Administi-ator oi- as a membei- of a committee desi�7ated as the Admnlistrator (uichiding any Employee
or fo�nlei• Employee who previously se�ved as the Adminish-atoi• or as a inember of such committee) �ganlst all
liabilities, damages, costs and expenses (including attorneys' fees and amounts paid in seCtlement of any claims
approved by the Plan S�o�7sor) occasioned by any act or o�r�ission to act in coi�nection with the Plan, if such act or
omission is in good faitli.
4.6 Insurance Contracts Control. Despite any other provision of tl�is Plan, if tl�e te��rns of this Plan and the terms of an
insurance contract which �funds a Qualified 13ei�efit Plan (as applicable) coi�tlict, t6e ter���s of such instu-ance contrac[
��ill co��h-o) ui�less conh-aiy to la���.
AI2TICLE V
Amendment and Termination
5.1 Ame»dinent of Plan. Tl�c Plan Sponsor rese�ves the ri�ht to amcnd this Plan at a��y time without the consent of
a»y Employee or Participai�t.
5.2 Termination of Pla�i. It is tl�e e�pectation of tl�e Plan Sponsor tl�at it will continue this Plan indefinitely, but the
continuance of tl�is Pla�� is not assumed as a contractual obligation of the Plau Sponso��, and the rigl�t is rese�ved to d�e
Plan Sponsor at any time for any reason to teri�iinate tl�is Pla�� �vitl�out liability. Upon termination of the Plan, all
elections and reductions in Con�pensation relating to thc Plan will Cei•minate.
5.3 Legal Enfoi-ceabilitv of Provisions. The Plan and the provisions l�ereof constitute a legally enforceable a�-eement
bctween the Plan Sponsor and a Participant.
ARTICLE VI
Claims Provisions
6.1 Claims Procedure. Claims for wlderlyiilg benefits undei- the Qualified Benefit Plan shall be governed by the clai�ns
procedures in tl�e applicable Qualified Benefit I'lan, except that claiuis with respect to eligibility for salary reductiolls
under tl�is P1an (such as fl�e ability to pay for Qualifiied Benet7t Plan coverage on a pre-tax basis) shall be submitted to,
and decided by, the Administrator.
ARTICLE VII
Miscellaneous
7.l Commu»icaCion to Em ��loyees. Promptly after tl�e Plan is made effective, the Plan Sponsor will notify all
Employees of its availability and terms. The Plau Sponsor will notify each new Employee of the availability and tertns
of the Plan as soon as practicable following the date the Employee commences his oi• her employment with the Plan
Sponsor. Within a i-easonable �eriod of time pi-ior to the comme»cement of each Plan Year, oi-, in the case of a newly
eligible Eiliployee, as soon as practicable followulg tl�e date on which he or she commences his or her employmeiit with
the Plau Sponsor, the Plan Spousor will provide to Employees booklets, brochures, or other explanatoiy items whieh
describe thc material �rovisions of tl�e Plan (to the extent the same have not been previously funlished).
7.2 Partici�ant's Rights. This Plan will not be deemed to constitute an employment contract between the Plan Sponsor
and any Pai-ticipant oi- to be in consideiation of or an inducement for the employtnent of any Participant or Employee.
Nothing contained ui this Plan will be deemed to give any Participant or Employee the right to be retained n� the seivice
of the Plan Sponsor or to i�lterfere wiCl� the right of the Plan S�onsor to discharge airy Participant or Employee at any
time regardless of the ef.fect which such discharge will have upon him as a Participant u� this Plan.
7.3 Protective Clauses.
(a) If a Participant fails to obtain coverage undei- any insured Qualified Benefit Plan (whedier as a result of the
negligence or gross neglect of the Plan Sponsor or othei-wise), such Participant's sole and exclusive remedy will be
the return of the amounC of the Employee Provided Premiums actually paid by such Participant nl tl�e Plan
Year(s) for which coverage was not obtained.
(b) If and to the extent paymcnts or reimbursell�ents due under an insured Qualified Benefit Plan �u�e required to
be paid to the Plan Sponsor, as agent� for a Participant oi� the spouse, Dependent or other beneficiary oF such
Participant or other-wise, the Plan Sponsor's liability for any claim brought by a Participant or by the spouse,
Dependent or otl�er beneficiary of a Participant with respect to such payinent or reimburseinents will be limited to
tl�e amount of tl�e payments or reimbursements, if any, actually received by the Plan Sponsor tl�ereunder in
connection with such claim. If payments or reimbursements under an insured Qualified Benefit Plan are not
ti�nely received by Che Plan Sponsoi- following the submission of a claim, tl�e Plan Sponsor will so notify tl�e
Pai-ticipant. Thei-eafter, the Plan Spo��sor- will have no obligation to pursue slicll claim, and the Participant may
pursue, settle or compromise such clav�� as the P�-ticipaut, in the sole exercise of his or he�- discretion, sees fit.
Page 8
(c) The Plai� Sponsor will not bc responsible ior thc valicliry of any insurance contract wl�ich fi�nds an insured
Qualified Benetit Plan or for the faihlre of an insurer to make payments provided for there�u�der, or- i�or thc actioi�
of any pei�son ��l�icli »�1y cause any sucl� ins��rancc contr��et to be i-cndered nlill �u�d void or unenforceable, in
whole or in part.
(d) Onee coverage under an i��sw-ed Qualitied Benefit Plan is applied for and obtained, the Plan Sponsor wi11 not
be liable for any loss which may result from the failure to pay premiums to the extent premilim notices are not
received by the Plan Sponsor. Where premiui�� noticcs are timely i-eceived by the Plan Sponsor-, tl�e Pla�l
Sponsor's liability for tl�e payment of premiw��s correspondiug to sucl� notices will be litnited to the dollar amouuT
of sucl� �i-cmiums and will not viclt�de ]iability for any other loss wl�ich may result from tl�e failui-e to pay such
prcmiums.
(e) The Plan Sponsor will not be liable for tl�e payi��ent of ai�y pr-emium due tmder a Qualified Benefit Plan or
any loss which may result fi-om the failw-e to pay such premitlm if thc amounts deferred under Sectioi� 3.3 are
insufficient to provide for the pay»�ent� of the Employee Provided Premium of a Qualified Benefit Plan at the time
such premium is due. Tl�e Plan Spo�isoi- will notify a P�i-ticipant if such a�nounts are insufficient to pay such
pi-emiwns but will not be liable for any faihlre to rnake such notification. Sucl� premiim�s may be paid (i) if
permitted uuder Code Section 125, put-suant to an a�nendment to a Participant's election under Section 3.3 or (ri)
otherwise, by a cash contriUution of the Participant.
7.4 No Gu�rantee of Tax Consec�uences. Neithcr tl�e Administi-ator noi- tl�e Plv� Sponsor makes any representation or
warranty that alry amount paid as prernitm�s oi- distributed as benefits under ai�y Qu�lified Benefit Plan will be
excludable fi-oin the gross income of a Participant foi federal or state income tax putposes. It will be the obligation of
each Pai-ticipant to detennn�e wl�ether payments ai-e excludable fi-om the Participant's ��oss nicome far federal and
state ulcome tax purposes.
7.5 Indemnification of the Plan Sponsor bv Participants"� lf any Participant receives payments or reimbursements which
do not qualify for exchision fi-on1 �-oss lllcon�e, sucl� Pai-tici}�ant will iudeinnify and reunbut�se the Plan Sponsoi• for any
liability it may nicur foi• failm-e to witlll�old federal oi- state tax fi-oin such payments or reimburscments, provided
however that such nidemni�cation and 1-eiinbtu-seinent ��ill not excced the ainount of additional federal and state tax
(together with any interest and penalties) that the Participant would l�ave owed if the payments or rennburseinents had
been made to tl�e Pat�ticipanC as regular- cash compensatioi�, less any such additiona] tax actual]y paid by the Participant.
7.6 Fuiid'ui�. Unless otherwise requv-ed by law, (i) contributions to th� Plan will be deemed general assets of the Plan
Sponsor until the amount thereof has been paid over to or under a Qualified Benefit Plan and (ri) nothing l�erein
contained will be consh-ued to require tl�e Plan Spoi�sor or the Admu�istrator to maintani any fund or segregate airy
amouut, in tiust or otherwise, for the benef3t of any Participant, and no Participant or other person will have any claim
against, right to, or securiry or other interest in, any asset of the Plat� Sponsor fi•om wl�ich any paymenY under tl�e Plan
n�ay be �nade.
7.7 Non-assi �nability of Ri ts. The right of any Participant to receive any amount under the Plan will not be alienable
by th� Participant by assi�ment oi- any other method, and will not be subject to the rights of creditors, and any attempt
to cause such right to be so subjected will ilot be recognized, except to such extent as may be requu-ed by law.
7.8 Lin7itation of Rights. Neitl�er the establishme»t of tl�e Plan nor any amendment thereof, nor the payment of any
bene��ts under this Plan, will be construed as giving to any Participant or other person any legal or equitable right
againsi the Plan Sponsor or Administrator, except �s provided herein.
7.9 Governing Law. Tl�is Plan will be construed, administer-ed and enforced according to the laws of Iowa, to the
extent not superseded by the provisions of the Code and any othe�- applicable federal law.
7.10 Effect of Mistake. I�i the event of a mistake as to tl�e eligibility or participation of an Employee, the allocations
made to the account of a1ry Participant, or the amount of�benefits paid or to be paid to a Participant or other person,
the Admuiistrator shall, to the extent that it deems admu�istratively possible and otherwise permissible under Code
Section 125 or the reb lations issues thereunder, cause to be allocated or- cause to be witl�held or accelerated, oi-
otherwise make adjustment of, sucl� amounts as it will in its jud�,n��ent accord to such Participant or other person the
ci-edits to tl�e account oi- distributions to which he oi- she is pi-operly entitled undei- the Plan. Stich action by tl�e
Administrator may include withholding of any amom�ts due to the Pla�i or the Employer fi-om Con�pensatio» paid by
the Employer.
7.11 Savings Clause. If a provision of the Plan or the apE�lication of a provision of thc Plan to any persoi�, entity, or
circui��stance is held invalid l�i�dcr governing law by a court of competci�t jurisdiction, the remainder of the Plan and Che
application of the pi-ovision to v�y otl�er person, cntiry, or circwl�stance s1�1ll not be affected.
ARTICLE Viil
llciinitions
As used ]�e3�eiu, unless tl�e context clearly indicates otl�erwise, the following words vld pl�rases wl�en capitalized
have the meanings herein specified. A pronow� or adjective in tl�e masculine gender iucludes tl�e femuln�e and neuter
genders, and the singular includes tl�e plw-al, unless the conteat clearly indicates a differeut meanvig.
8.l "Administrator" �ncans the Plan Sponsor or such other person or com�nittee as may be appointed fi-om Cime to time
by the Plan Sponsor to supervise the administration of the Plan.
8.2 "Affiliated Einployer" means the Plan Sponsor and any coipoi-ation, listed on Appendix A, which is: (i) a member
of a controlled g�oup of co�porations (as defined in Code Sectioi� 414(b)) wl�ic}� ii�cludes the Plan Sponso�; (ii) any
trade or business (wl�etl�er or- not incorpoiated) wl�ich is under common control (as deti»ed in Code Section 414(c))
with the Plan Sponsor; or (iii) any organization (whether or not ii�corporated) which is a me»�ber of an affiliated seivice
group (as defined in Code Section 4l4(m)) which includes the Pla�� Sponsor; and any other entity required to be
ag�,n-egated witl� the Plan Sponsor plii•suant to Treasu�y regul�tions under Code Sectioi� 414(0).
8.3 "Code" means the Internal Revenue Code of 1986, as amended.
8.4 "Compens�tion" means tl�e total casl� remuneration received by a Participant fi-om the Plan Sponsor diu-iug a Plan
Year prior to any reductions under Section 3.3. Coinpensation includes overtnne, commissions and bonuses.
8.5 "Contract Period" means the l 2-month per-iod ending with or wid�in the Plan Yea�- whicl� will be designated by tlie
AdministraCor for purposes of making or changing benefit electio��s under This Plan, except as provided in Section 3.3(a)
(relaCing to tl�e election of benefits by a newly eligible F,mployee).
8.6 "Dependent" means any �erson who falls witl�i�� the definition of dependent under Code Section 152, as modified
by Code Section 105(b), and any child of a Participant as de��ned in Code Section ] 52(�(1) until tl�e end of tl�e year in
which the child attains age 26. NotwithsCanding anything in the Plan to the contrary, any pre-tax payments made
pw�suant to tl�e Plan with respect to a domestic partner and/or the cl�ild of a domestic pa3•tner wl�o does not qualify as
tl�e Employee's Dependent shall be treated as taxable compensation. This taxable compensation shall be treatEd as
wages reportable on the Employee's Form W-2 and sliall be sl�bject to uicome tax and social security tax withholduzg.
8.7 "Employee" means any individual employed by the Plan Sponsor. I-Iowever, only those individuals classified as
"employees" by tl�e Plan Sponsor- shall be eligible to par-ticipate, including any ]eased employees within the meaning of
Code Section 4l4(n)(2). Inde�endent conh•actors, freelancers and ii�dividuals hired througl� staffing firms shall not be
eligible to participate in the Plan even if tl�ey are subsequently determined to be con�mon law employees for any
purpose, inchidi»g without limitation, for wage, labor or tax purposes by either the Internal Revenue Service,
Department of Labor or any other Federal or state agency, admu�istrative body or court. An einployee shall not include
any self-employed individual, parmer in a partnership, and more-than-2% shareholder in a Subchapter S corporation.
8.8 "Employee Pi•ovided Premium" means d�e sum of (i) tl�at portion of tl�e total premium cost of a Qualified Benefit
Plan that requires payment of premiums, which is required to be paid by tl�e Employee, eitl�er by law or by agreement,
and depending on wl�at options exist w�der sl�ch plan (c.g., to the extent applicable, individual or family coverage, high
or low deductibles, etc.), as adjusted fi-oin time to tiine to reflect changes, if any, nl the percentage of such premiums
paid by the Employee and/or ehanges u7 the total amount of sucl� premituns, and (ii) a pro rata share of the costs of tl�e
administration of the Plan (allocated on a uniform basis) to t}�e extent that the Plan Sponsor detennines that such costs
will be borne by Participants pursuant to Section 4.2.
8.9 "Participant" mea»s an Employee who participates i�� the Pla�� in accordance with Article II.
8.10 "Plan" means the City of Pairfax Section 125 Plan as set forth hcrei��, togetl�er with all amendments and
restatements.
8.11 "Plan Sponsor" means City of Fan-fax �nd any Affiliated Employer who adopts the Plan pursuant to authorization
provided by the Plan Sponsor. Notwithstandu�g the previous sentence when the Plan provides that the Plan Sponsor
Page 10
has a certain po�vcr (e.g., the appointment of a third parry ad���inistrator, entering inCo a contract with a third party
insw�er, or amei�dment or termii�atioi� of the F'lan) the tcnn "Plan Sponsor" shall i��ean only City of Fairfax. Aftiliated
Fmployers who �dopt thc Plan sl�all bc bolu�d by thc P1�» as adopted and subsequently amended unless they clearly
witl�draw fi-om participation l�crci». Affiliated Employcrs ���ho have adopted thc Plan �u-e set forth in Appendix A.
8.12 "Plan Year-" means the twelve-month period ending each Januaiy 31st.
8.13 "Qualified Benefit Plan" r�efer-s to any e�nployer-spo�lsoi-ed welfai-e benef7t plan designated fi-om time to time by
the Plan Sponsor, and co�nmunicated in ���ritv�� to Participants, for pwposes of providing various benefits under this
Plan.
8.14 "Uniformed Se�vices" means the United States nrmy, Navy, Air Force, Marine Coips, Coast Guard, tl�e Arnry
National Guard, �nd the Av- I�iational Guard whe» engaged in active dl�ty for traniv�g, ulacCive dury trauiing, oi- full-tin�e
National Guard duty, tl�e cominissioned corps of tl�e Public Healtl� Service, and any otl�er category of persons
desiguated as sucl� by tl�e President of the United States v� time of war or einergency.
Executed this day of , 2024.
City of Fairfax
C
Name:
Title:
Page 11
APNElVDIX A
PAR77CIPATING EMPLOYERS
As oi' Feb�va�y 1, 2024
Eacl� entity listed below l�as sufficient common ownersl�ip witl� tl�c Pl�u� Sponsoi- so �s to constitute a meinber of a
commonly conti-olled gi-olip as described in Code �414(b), (c), (�n) or (o) and has adopted tl�e Plan with the consent of
tl�e Plan Sponsor.
None
Page 12