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UnitedHealthcare <br />® A UnitedHealth Group Company <br />r+ r <br />;A-2010-164 01.. <br />CITY OF SANTA ANA <br />RENEWAL AGREEMENT <br />Contract Period: <br />Flexible Spending Account Plan Services: <br />Annual Renewal <br />Record-keeping 8L Claims Administration <br />Annual Report Form 5500 <br />Plan Amendments <br />Annual Account Statements <br />Sent to employer for distribution <br />January 1 through December 31, 2012 <br />$750 <br />$3.75 per participant per month <br />$1 SO per filing <br />$100 per amendment <br />No charge <br />ATTEST: <br />?? ? - ??? <br />MARIA D. f-Pi:.311AR <br />CLERK OF ? f-dE COUNCIL <br />CITY OF SANTA <br />Accepted By: <br />Signature - as an authorized party of the Employer <br />Print Name: S a.ll? I?U\ . ?.??'L?-?' L' 1/^'? <br />Title: 1-- V'1?-E? if ? Vin C??i? u ?°?%? GI.?IU ?=t C? {?' <br />Date: ?i?'1?/ C1 4 21377 <br />Sim and return to attention of Donna Labisch by September 1.201 1 <br />LAIC BENEFIT SERVICES MAILING ADDRESS <br />250 N. PATRICK BOULEVARD P.O. BOx 2490 <br />SUITE 125 BROOxIaELD, wI 53008-2490 <br /> <br /> <br /> <br />ROOKFIELD, WI 53045-5876 262 789.$1$1 <br />800 236.8187 <br />FAx 262 879.0720