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DocuSign Envelope ID: CFCE3443-EF37-4FD4-80CD-D85D559F77AE <br />1. Terms and Conditions <br />a. Spending Account Services — Contract Administrative Firm Duties <br />i. In accordance with the terms of this Agreement, including language specific to <br />each component of Client's Spending Account Program as identified in Exhibit B <br />to this Agreement, but excluding language pertaining to components not <br />selected as part of the Client's Spending Account Program or components <br />selected by Client but administered by a third party firm other than Igoe, or by <br />Client itself, the Contract Administrative Firm shall provide the following <br />administrative and clerical functions: <br />1. The Contract Administrative Firm shall consult with the Client on the <br />design of the Client's Spending Account Program. The Contract <br />Administrative Firm shall provide the Client with the following sample <br />documentation in order to initiate the administrative function; <br />a. Data collection forms and/or annual client verification forms <br />that outline the specific details of the Client's Spending Account <br />Program; <br />b. Sample Spending Account documentation corresponding to the <br />component reimbursement accounts comprising Client's <br />Spending Account Program for review and potential adoption by <br />the Client in its capacity as the Plan Administrator/Plan Sponsor <br />as defined by the Employee Retirement and Securities Act of <br />1971 (ERISA) § 3(16) if applicable; <br />c. Sample written summaries of the reimbursement accounts <br />comprising Client's Spending Account Program explaining the <br />rights and responsibilities of participants thereunder for review <br />and potential adoption by Client in its capacity as the Plan <br />Administrator/Plan Sponsor as defined by ERISA § 3(16) if <br />applicable; <br />d. A master set of spending account participant (Participant) <br />communication and enrollment materials, if applicable, <br />including: <br />i. Election forms to be used during the enrollment <br />process; and <br />ii. Electronic file transfer specifications; and <br />iii. Reimbursement request forms, which include <br />instructions for filing requests. <br />The Client is not required to use the sample election forms or <br />enrollment materials provided, subject to review by the <br />Contract Administrative Firm. The Contract Administrative Firm <br />J- <br />/GOE <br />.... <br />City of Santa Ana Spending Account Administrative Services Agreement <br />Client Initials: <br />PEPM17 <br />Page 3 <br />25A-5 <br />