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HomeMy WebLinkAboutICMA-RC RHS PLAN AMENDMENT (CITY MANAGER)A-2015-023-0a INSURANCE NOT ON FILE WORK MAY NET PROCEED CLERK OF CNUNL DAT jD I?olWILY, I A VantageCare Retirement Health Savings (RHS) cG•PP1 Aft'" BUILDING PUBLIC SECTOR RET",,,ITT"I'll" PLAN AMENDMENT PACKET 61J 6-053 To amend your existing R14S Plan, please complete the entireAdopdon Agreement, including items that are not being amended. When you send your amendment ro IC1vLk-RC, please summarize the changes in your cover letter. Please note that ICMA-RC does not require the use of a resolution to amend the plan. Should you require legislative action, you may use the Suggested Resolution for Amendment on the following page. If you do not regdun legislative action, you may complete the Suggested Affirmative Statement for Amendment which Follows. Once the amendment is completed, retain a copy For your records and send she original Witt, the cover letter and either the resolution or the affirmative statement to rCMA-RC as Follows: Via Mae ICM -RC Arm — New Business Services Suite 600 777 North Capitol Street, NE Washington, DC 20002-4240 Via Facsimile 202-962.4601 Arm —New Business Services You will receive notification that your amendment has been received and accepted. AC., 30662-091 & tr14( 2 EMPLOYER VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) ADOPTION AGREEMENT 102 VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) ADOPTION AGREEMENT Plan Number: 8 03550 Select as applicable: ❑ Standalone RHS ❑ lnregtated RI -IS [{Z Amendment to Existing Plan ❑Now Plan I. EmployerNamaa City of Santa Ana State: CA II. 'Ilia Employer herebyattests that it is a unit of a state or local government of an agency or instrumentality of one of more units of a state or local government. Ili. Plan Antes: A. Plan Effective Dare 5/=19,_,,,e__„___ B. P1ati Vear: Enter the annual accountlug period for the RI IS program. _ IV, The Employer intends to atilixe the. Trust to fiend only welfare benefits pursuant to the following welfare benefit plan(s) established by the Employer: Citv of Santa Ana Retiree Wad V. Eligible Croups, Participation and Participant Eligibility Requirements A. Eligible Groups The following group or groups of Employees are eligible to participate in the Employer's welfare benefits plan identified in Section 1V. (check all applicable boxes): ❑ All Employees ❑ All Pull Thr e Employees ❑ Non -Union Employees ❑ PublicSafetpEmployees— Police ❑ Public Safety Employees — Firefighters ❑ General Employees ❑ Collectively -Bargained Employees (Specify unh(s)) _ 0 Other (specifygroup(s)) CltV Manager The Employee group(s) specified must correspond to a group(s) of the same designation that is defined in the statutes, ordinances, rules, regulations, personnel manuals or other documents or provisions in effect in the state or locality of the Employer. B. Participation AfaueMtoty Pdrticipat;on: All Employees in the covered group(s) are required to participate in the Plan and shall receive contributions pursuant to Section VI. If the Employees u ndulyingwelfare benefit plan is in whale or part a non -collectively bargained plan that allows' reimbursement for medical expenses other than insurance premiums, the nondiscrimination rcquircments of Internal Revenue Code (IRC) Section 105(h) will apply. These rules may impose taxation on the benefits received by highly compensated individuals if the Plan discriminates in favw of highly compensated lodividuals !it terms of i eligibility or benefits. The Employer should discuss these rules with appropriate counsel, 11:13 C. Participma Eligibility Requirements I. Minimum service: The minimum period of service required for participation is N,jj (write N/A If no minimum service is required). ��111�,66 2. Minlmm aage: The minim _ um age required for eligibilicy to participate is aa (write N/A if no minimmn age is reyuieed). VI. Contribution Sources and Amounts A. Def dtion of Earnings The defnition ofEarnings will apply to all RHS Contribution Features that reference "Earnings including Direct Employer Contributions (Section VI73.1.) and Mandatory Employee Compensation Contributions (Section VLB.2.). Definition oFearnings:AS defined b�LClt�LMana_ger___ EfnploYment Agreement A. Direct Employer Contributions and Mandatory Contributions 1, Direct Employer Contributions The Employer shall contribute on behalf of each Participant ❑ %ofEamings* ❑ $ _ each Plan Year ❑ A discretionary amount to be determined each Plan Year ❑ Other (describe): 2. Mandmory, Employee Compensation Contributions The Employer will make mandatory contributions of Employee compensation as follows; Q Reduction in Salary - 1.25 % of Earnings or $—_—will be contributed for the Plan Year. ❑ Decreased Writer Pay Plan Adjustment -All or a portion of the Employees' annual merit or pay plan adjustment will be contributed as follows: An Employee shall nnr have the right to discontinue or vary the rate of Mandamry Contributions of Employee Compensation. 3. Mandatory Employee Leave Contributions The Employer will make mandatory contributions of accrued leave as follows (provide formula for determining Mandatory Employee Leave contributions): pp AccruedSick 100% Qf S't kC JELaKe CaSfj w _ ❑ Accrued Vacation Leave p Other (specify type of lease) Accrued Min Leave Unused,Longe_vijV nd Reggular Vacatiop Must Use time contributed cannot enen An Employee shalt not_have the right to discontinue or vary the rate of mandatory leave contributions. '.(Von-ca(lecteaely baryainedplaur dent reimburse "welical expenses otho- then itd+arr'vtce pren+ittnrufmrzld cottsns their benefits evitwed regarding ue fkre pl,in nondherindn.ation rides i(tbe employer elver to inake eontribntions 6ntzd ire ra perrcntaga ufznrrrGtgs. C. Lhults on Totatl Connributions (check one box) 'The total contribution by the Employer on behalf ofeuch Participant (including Direct Finployer and Mandatory Employee Contributions) for each Plan Year shall not exceed the following limit(s) below. Limits on Individual contribution types are defined within the appropmue section above. 0 There is no Plan -defined limit on the percentage or dollar amount of earnings that maybe contributed, [] __.__ % of earnings Definition of earnings: [] Same as Section VT.A. ❑ Other 0 $ _for the Plan year. VI1. Vesting for Direct Employer Contributions A. Vesting Schedule (check one box) © The account is 100% vested at all times, d The following vesting schedule sludl apply to Dircct Employer Contributions as outlined in Section VIR L: Years orservice "Vesting Completed Percentage ly __ nitl B. Tite account will become 100% vested upon the death, disability, retirement`, or attainment of benefit eligibility (as outlined in Section LX) by a Participant. *Definition of retirement Includes a separation from service component and is further defined by (check one): a The primary retirement plan of the Employer © Separation from service El Other _ C. Any period of service by a Participam prior to a rehlre of the Participant by the Employer shall not count toward the vesting schedule outlined in A alcove. VILL [forfeiture Provisions If a Participant separates from service prior to full vesting, non vested funds in the Participant's account shall he forfeired in accordance with the box checked under this section. Upon the death of a participant, surviving spouse, and all surviving eligible dependents (as outlined. in Section Xl), funds remaining in the Participants account shall be revert to the "Trust in accordance with the box checked under this section. lhi5 Va Participant permanently opt.+ our and waives (otUVC relmbursnmenes, as allowed tinder IRS Notice 2013-54, all funds in the Participant's accountat the time of waiver shall be forfchcd in accordance with the box checked under xhissection? ❑ Remain in rho Trust to be reallocated anwng tell Plan Participants with a balance as Direct Employer Contributions for the next and succeeding contribution cycle(s)." Z Remain in the Trust to be reallocated on an equal dollar basis among all Plan Participants with a balance.*" ❑ Remain in the Titut to be reallocated among all Plan Participants based upon Participant account balances," ❑ Reverr to the Employer via check. IX. Eligibility Requirements to Receive IvIcilical Benefit Payments from the Vurnagi Care Retirement Health Savings Program A. A Participant is eligible to. receive benefits; ❑ Ax retheoem only (also complete Section B.) Definition of retirement: ❑ Same as Section VIIA ❑ Other © At sepuation lino service with the following resaictions [] No restrictions ❑ Other B, Termination prior to general benefit eligibility: In case where the general benefit eligibility as outlined in Section IX.A includes a retirement component, a Participant who separates from service of the Employer prior to retirement will be eligible to receive benefits: M Immediately upon separation front service ❑ Other— C. AParticipmrtthatbenomestotaUyandpermanentlydisabled ❑ as defined by tlhe Social Secrtriw Adntinistrariort ❑ as defined bytltcEmployer's primary redremeittplm ❑ other___ will become immediately eligible to receive medical benefit payments from his/her account under the Employer's welfare benefits plan. D. Upon the death of the Participant, benefits shall become payableas outlined in Section X.I. "lftbe 6'mplayers RATS Program does not lhnir eligibility to penticlpants who have separareel fivni service, the ernphyer twill be required to provide funkier doertion to7CAM-RC reparding the treatment ofpos able contributions t/oat are )equiroel to be meth following the participants rvarver. Lf the forfeited balance is small whereby the reallocation ammrnt to each Plan Participant with a balance is ntininial, the assets will revert to nruployerF forfeiture ,rccnwic forlvtrtfiar dirzzrioulrovt the eraplaycr. Ifthrre are partiripaats euithnnr a Prmlance elm shmrlrl rerdlve foi fzittrru assets, please provide altrrurttix`c iiutructiomr to /CM:I-RC' oa tfie for fritura reallncatian notice 11:1G X. Permissible Medical Benefit Payments Biowfin eligible for reimbursement consist of [0 All Medical Expenses eligible under IRC Section 213 ocher than (i) direct long-term care expenses, and (ii) expenses for medicines or drugs which arc nor prescribed drugs (other than insulin). ❑ The following Medical Expenses eligible under IRC Section 21;g otter than (i) direct long -terns care expenses, and (ii) expenses for medicines or drugs which are nor prescribed drugs (other than insulin). Select only die expenses you. wish to cover under the Employer's welfare hcnerics plan: ❑ Medical Insurance Premiums ❑ Medical Out-of-pocket Expenses* ❑ Medicare Part B Insurance Premiums ❑ Medicare Part D Insurance Premiums ❑ Medicare Supplemental Insurance Premiums ❑ Prescription Drug Insurance Premiums ❑ COBRA Insurance Premiums ❑ Dental Insurance Premiums ❑ Dental Out -of -Packer Expenses* ❑ Vision Imuranca Premiums ❑ Vision Otte-ol~Pocket Expcnses` ❑ Qualified Long -Term Care Insurance Premiums ❑ Non -Prescription medications allowed under IRS guidance Other qualifying medical expenses (describe)* Non-tn(lrerively bruganredplans that rcimbrase medical expenses other than insiurnece presduncrsbould znnsult their benefus couruel regarding ioeyyere plu: rtnndlsariminrzrlon rules if the oniplayer elects to snake contributions baud on a percena,;e of earrings. XI. Benefits After the Deathof the Participant In the event of Participant's death• the following shall apply: A. SurvivingSpouse and/or Surviving Dependenrs Upon the death of participant, the surviving spouse andlor surviving eligible dependents (as defined in Section XII.D.) of the deceased Pmrticipa irate immediately eligible to maintain the Parriciparns RHS account mad utilizing the remaining balance to brad eligible medical beneflcc specified in Section X above. Upon notification of Paxdcipcuu's death, the Parncipant s account balance will be transferred into VT II Cash Management Fund" (or another fund sclecred by the Employer). The account balance may he reallocated by die surviving spouse or dependents, "* Before investing in the Frnrd yn shoulhicarefaly consider your invesmienrgoab, rolerance for risk, investment time horizon, and personal cirvxtnuunues. There is no gummrree thar the Fund mill meet its lnvestrnenr objerrivr rind you can lose money. For ail boom/ information regarding the Franc,, including a description of the principal risks, please consult the hanrarcTrvst pl cords Diselosure Afenorramlam and fund fitet sheer, which is available whom you log in at wiara.icmenrbrg or Open requen by eallhtZ 800,669-7400, f the pin i defaulr fund is nor rbe VT Il Cash Management Fund, please, read the disclosure nrrtterhuh or prospectus applicable to the deyealijaml If a Participant's account balance has not been fitly utilized upon the death of the eligible spouse, the aceounr balance may continue to be utilized to pay benefits of eligible dependents. Upon the death of all eligible dependents, the account will revert in accordance with die Employer's election under Section Vil l of the I4utrageGare RHSAdoprimr Agreement, 11:17 E. Na Surviving Spousc or Snrviving Dependents If thereareno living spouse or dependents at the time of death of the Participant, the account will revert in accordance with the rmployvr's election tinder Section V III of the VawageCare A''I^I.SAdeption Agreemene, XII,'.the Plan will operate according to the following provisions: A. Employer Responsibilities 1. The Employer will submit all VatuageCgre Retirement health Savings Plan contribution data viaelectronie submission. 2. The Employer will submit all VantageCare Retirement Health Savings Plan Participant status updates or personal information updates via electronic submission This includes but Is not limited to termination notification, benefit eligibility, and vesting notification. E. Participant account administration and asset -based fees will be paid through the redemption of Participant account shares, unless agreed upon otherwise in the Administrative Services Agreement. C. Assignment of benefits is not permitted. Benefits will be paid only to the Participant, his/her Survivors, the Employer,or an insurance provider (as allowed by the claims administrator). Payments to a rhird-party payee (e.g., medical service provider) are nor permitted with the exception of reimbursement to rho Employer or Insurance provider (as allowed by the claims administrator). D. An eligible dependent is (a) the Participant's lawful spouse, (b) the Participands child under the age of 2Z as defined by2RC Section 152(f)(1) and Internal Revenue Service Notice 2010-38, or (c) any other individual who is a person described in IRC Section 152(a), as clarified by Internal Revenue Service Notice 2004 79. E. The Employer will be responsible for withholding, reporting andremitting any applicable taxes for payments which are deemed to be discriminatory under IRC Section 105(h), as outlined In the VamageCare Retiremenr Health Saving Employer Manual. XIII. Employer Acknowledgements A. The Employer hereby acknowledges it understands that failure to properly fill out this VantrrgeCam Retirement Health SavinSoAdnptivn Agmane rt may result in the loss of tax exemption of the Trust and/or loss of tax -deferred status for Employer contributions. E. ® Check this box if you are including supporting documents that include plan provisions. EMPLeOia,11C , Attesta r '�.� k A -a Arthg-der o e Councii 11: l8 APPROVED AS TO FORM ) .-Rfs t Laura A. Rossini Senior Assistant City Attorney Employer VantageCare Retirement Health Savings (RHS) Adoption Agreement Amendment Plan # 803550 May 1, 2019 IV. - City of Santa Ana Welfare Benefit Plan VI. B.3. Other — Accrued Must Use Leave: Unused Longevity and Regular Vacation designated as Must Use leave as of December 3111 each year. The maximum allowable must use time contributed cannot exceed the allowable cash applicable for that Fiscal Year and/or Calendar Year. /+ CERTIFICATE OF LIABILITY INSURANCE DATE JMM(DD/YYYY) 9elo7maa THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER MARSH USA INC CONTACI NAME` PAtG. 1050 CONNECTICUT AVENUE SUITE 700 N2.EXi1;___—.LA1X WASHINGTON, DC 20038 5386 -MAIL ADORES,S:....—__._�._..._.._�....,_ INSUREIRIS1 AFFORD No COVERAGE NAICM GN101976702-MULTI-EO41-18-19 IN IJRERA: O:eat Ne?NIONAI SUrance Cemeany 20303 _ INS ICMA RETIREMENT CORP, INSURER 6: NIA N/A INSURERS: Pacific Indemnity Insurance Company__20346 _ - ATTN: D'JUANA THOMAS 777 NORTH CAPITOL ST„ HE INSURERtl Federal Compa,,!,IN._ 20281 WASHINGTON, OC 20002 ,IpsylencD INSURERS Travelers Casually Id Surety 31194 INSURER F COVERAGES CERTIFICATE NUMBER: CLE-006041484-38 REVISION NUMBER: 5 'THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN9R_. ..___�_.... _ .....—.,..._ ....._... ADOLs BR __.._..._._...� ...... POLICY EFF..... P6LICYEXF" _........_..._. ,_,.._,.._-- ._ .__... _....._ L TYPE OF INSURANCE POLICYNUMBER IMMIDDIYYY (MMIDDNYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY 360449„95 08/0112018 0810112019 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE IE OCCUR 'UA AG, E EG.—_—.._...—_ r`RE ISE „ Ee.MFe _.._ $ 1,000,000 _— — X CONTRACTUAL OV INCL—^-_.... MLU EXF A one �arsvn t ro .$ PERSONAL&ADV INJURY_ $ 00,000 1,010000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JECT X LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY _(Ea COMBINED SINGLELIMIT acadenl) _ $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(PnI.Aodenp 7 HIRED NON -OWNED PROPERTY DAMAGE „ $ AUTOS ONLY AUTOS ONLY y_PW-ddan�__,,, UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB _CLAIMS -MADE AGGREGATE $ CEO RETENTION$ $ C WORKERS COMPENSATION 08101/2018 ublujl2ulB X P R I OTH- STATUTE ER AND EMPLOYERS' LIABILITY YIN ANYPROPRI ETOWPARTN ERIEXECIJTIVE EL EACH ACCIDENT $ 1000000 OFFICERIMEMBrI EXCLUDED? F7N NIA — "'-' --- (Mandatory In NH) EL DISEASE -EA EMPLOYEE $ 10000UU Iliac, describe under DESCRIPTION OF OPERATIONS below ,..-......— E,L. DISEASE -POLICY LIMIT __— . .. $ 1,000,000 D BANKERS PROF. HAS 8211„0261 06130I2018 06/30120f9 $7,500,000 ek,$i2,500,000 E SIR:$1,000,000 106758967 06130/2018 06/3012019 $5,000,000 ice $12,500,000 DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (ACORD101, Additional Networks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION CIT YOF SANTA ANA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN: EXECUTIVE DIRECTOR OF PERSONNEL SVS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 20 CIVIC CENTER PLAZA M-34 ACCORDANCE WITH THE POLICY PROVISIONS, SANTA ANA, CA 92702 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ©1g66-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CNIO1976702 LOC #: Washington .�C"R as ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED MARSH USA INC. ICMA RETIREMENT CORP. ATTN: D'JUANA THOMAS 777 NORTH CAPITOL ST., HE POLICY NUMBER WASHINGTON, DC 20002 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance FIDELITY BOND/CRIME: CARRIER: Great American Insurance Company POLICY NO.: FS 234-63-54 EFFIEXP: 06/3012018 - 0613012019 LIMIT:$25,000,000 DED:$250,000 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD RESOLUTION NO. 2016-053 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF SANTA ANA TO AMEND RESOLUTION NO. 2011-080 TO AFFIRM THE APPOINTMENT OF THE EXECUTIVE DIRECTOR OF PERSONNEL SERVICES, OR HIS OR HER DESIGNEE, AS THE CITY'S RETIREMENT HEALTH SAVINGS PLAN ADMINISTRATOR AND AFFIRM THE APPOINTMENT OF THE EXECUTIVE DIRECTOR OF FINANCE AS THE CITY'S PLAN TRUSTEE. BE IT RESOLVED B`:THE CITY COUNCIL OF THE CITY OF SANTA ANA AS FOLLOWS: Section 1: The City Council hereby finds, determines and declares as follows: A. On November 28, 2011, the City Council adopted Resolution No. 2011- 080 adopting the ICMA-RC VantageCare Retirement Health Savings Plan ("RHS) accessible to all bargaining groups and authorizing the deposit of existing (at the time) medical retirement subsidy funds for participating bargaining units Into the RHS trust and distributed equitably to current and retired bargaining unit members. Each bargaining unit was allowed to determine how the existing funds will be split among their membership and it was determined that any future negotiated City contributions for participating bargaining units would be deposited into the RHS trust. Resolution No. 2011-080 authorized the City Manager and Executive Director of Personnel or their respective designees to execute any documents required in furtherance of the establishment of the health savings plan. C. It is now desired to amend Council Resolution No. 2011-080, in order to effect the changes, as shown below: Section 2: The Santa Ana City Council amends Resolution No. 2011-080 to affirm the appointment of the Executive Director of Finance, or his or her designee, as the City's Plan Trustee authorized to maintain compliance with any regulations regarding the trust for the VantageCare Retirement Health Savings Plan and make changes as necessary to the RHS plan investment options available to plan participants. Section 3: The Santa Ana City Council amends Resolution No. 2011-080, to affirm the appointment of the Executive Director of Personnel Services, or his or her designee, as the City's Plan Administrator for the RHS Plan, authorized to implement the RHS plan, amend the RHS plan, and to take additional actions as necessary to maintain the City's participation in the RHS plan, and to administer the RHS plan. Resolution No, 2016-053 Page 1 of 2 ry�/ 1/(rye ® i]! —.. V - - DATE IMMIDDNYYY) CGIFc� CERTIFICATE OF LIABILITY INSURANCE 07I0212019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the Certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER MARSH USA INC. 1050 CONNECTICUT AVENUE, SUITE 700 WASHINGTON, DC 2DO36-5385 CON ACT NAME: PHONE I KC. Nol: EX. 60"AIL12 ADDRESS: INSURER(S)AFFORDINO COVERAGE NAIC# INSURER A: Great Northern Insurance Com an 20303 CN101976702-MULTI-EO+FI-19-20 INSURED ICMA RETIREMENT CORP. ATTN: D'JUANA THOMAS INSURERB: NIA NIA INSURER C: Padfic Indemnity Insurance Company 20346 INSURER D : Federal Insurance Company 20281 777 NORTH CAPITOL ST., NE WASHINGTON, DC 20002 - INsuRERE:Travalars Casualty And Surety Company Of America 31194 INSURER F COVERAGES CERTIFICATE NUMBER: CLE-006041464-38 REVISION NUMBER: 5 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INS. LTR TYPE OF INSURANCE ADOL SUER POLICYNUMSEft MMIDIDIYYYY POLICYXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR CONTRACTUAL COV. INCL, 3604-49-95 08/01/2018 0810112019 EACH OCCURRENCE $ 1,000,000 DAMAG oo IIENTL PREMISES Ea occurrence $ 1,000,000 X MED EXP (Any one parson) $ 10,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: POLICY F j p7 LOC OTHER: GENERALAGGREGATE $ 2,000,000 PRODUCTS - COMPIOP AGE $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE 1 1 EACH OCCURRENCE $ AGGREGATE $ DEO I I RETENTION$ $ C WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN1,000,000 ANYPROPRIETORIPARTNERIEXECUTIVE —NIA 0FFICENMEMB ER EXCLUDED4 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below 7176-36-85 08101I2019 X STATUTE ERH E.L. EACH ACCIDENT $ E.L. DISEASE-EAEMPLOYEE1$ 1,000,000 - E.L. DISEASE -POLICY LIMIT $ 1,000,000 D E BANKERS PROF, LIAB. SIR: $1,000,000 8211-6261 106758967 06/30/2019 06/3012019 06/30/2020 06/30/2020 $7,500,000 plo $12,500,000 $5,000,000 PIC $12,500,000 DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES (ACORD 1111, Additional Remarks Schedule, maybe attached If more space is requlred) CITY OF SANTA ANA ATTN: EXECUTIVE DIRECTOR OF PERSONNEL SVS 20 CIVIC CENTER PLAZA M-34 SANTA ANA, CA 92702 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashl Mukherjee CORPORATION. All riahte reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101976702 LOC #: Washington ACd l ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED MARSH USA INC. ICMA RETIREMENT CORP. ATTN: UJUANA THOMAS 777 NORTH CAPITOL ST., NE POLICY NUMBER WASHINGTON, DC 20002 CARRIER NAIL CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate Of Liability Insurance FIDELITY BOND/CRIME: CARRIER: Great American Insurance Company POLICY NO.: 234-63-54 EFF/EXP: 06/30/2019- 06/3012020 LIMIP.$25,000,000 DED:$250,000 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD Rojano, Michael From: Mitre -Ramirez, Norma Sent: Wednesday, July 10, 2019 8:39 AM To: Rojano, Michael Cc: Hanes, Carrie Subject: FW: City Manager's RHS Agreement Attachments: RHS Plan Amendment Packet A-2019-013-01 CM Revised 2019.pdf; RE: ICMA - RHS Plan Amendment #03550; RE: ICMA - RHS Plan Amendment #03550; Resolution signed by Council 2011-80.pdf; 2016-053.pdf; Amendment to RHS-approved as to form 6.5.19.pdf Hello Michael, Please see attached resolution 2016-053 providing signature authority to Director of Human Resources for RHS. I have asked Carrie to reflect the resolution number that applies to all forthcoming agreements on the COTC processing, in the Comment's section of the form to assist in processing the agreement(s). Thank you, Norma Mitre Acting Clerk of the Council Department 20 Civic Center Plaza I Santa Ana, CA 92701 714-647-6520 1 nmitre@santa-ana.org http://www.santa-ana.org/ This e-mail (and attachments, if any) may be subject to the California Public Records Act, and as such, may, therefore, be subject to public disclosure unless otherwise exempt under the Act. From: Hanes, Carrie <CHanes@santa-ana.org> Sent: Wednesday, June 26, 2019 5:20 PM To: Mitre -Ramirez, Norma <NMitre-Ramirez@santa-ana.org> Subject: City Manager's RHS Agreement Hi Norma, I have received back the most recent City Manager's RHS Plana mend me nt for the second time. I am attaching a copy of the amendment that was just amended in January of this year for Raul Godinez. I am going to give you a call regarding this, I think this could be resolved over a quick phone call as to not delay the City Manager's RHS plan agreement any further. Thank you, Carrie Hanes Benefits and Compensation Manager City of Santa Ana Human Resources Ph (714) 647-6967 � oq 3anta� G [e1rL 8 CONFIDENTIALITY NOTICE: This communication and its attachments may contain non-public, confidential, or legally privileged information including HIPAA-protected PHI. The interception, use or disclosure of such information is prohibited. If you are not the intended recipient, or have received this information in error, please notify the sender immediately by reply email and delete all copies of this message and attachments without reading, saving, or further distributing them.