OxfordFlex SM Employer Application Attn: OxfordFlex Enrollment Department, P.O. Box 1021, Eatontown, NJ Phone: ; Fax:

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1 OxfordFlex SM Employer Application Attn: OxfordFlex Enrollment Department, P.O. Box 1021, Eatontown, NJ Phone: ; Fax: I. G E N E R A L I N F O R M A T I O N OxfordFlex SM Healthcare OxfordFlex SM Dependent Care OxfordFlex SM Transit OxfordFlex SM Parking Name of Employer Subsidiaries (please list) Street Address City State Zip Code Tax ID Number Number of Employees Employer Contact Phone ( ) Title Fax ( ) I I. A D M I N I S T R A T I V E I N F O R M A T I O N Please note: Current law provides that OxfordFlex Healthcare and Dependent Care plans, offered as part of a Section 125 qualified cafeteria plan, may benefit only employees. While sole proprietorships, LLC, LLP, partnerships and S corporations can sponsor FSA s, tax law does not allow owners and partners to personally participate in an FSA. For S corporations, the prohibition applies to owners with 2% or more stock and their spouses, children, partners and grandchildren employed by the S corporation. A. Plan Year Plan Start Date (MM/DD/YYYY): Plan End Date (MM/DD/YYYY): B. Eligible Class of Employees (Check One) Note: Plan will renew on the following day. All employees Salaried Employees Only Hourly Employees Only All Employees Except: (Check all that apply) Commissioned employees Other: Note: OxfordFlex employers and Members may want to consult a tax advisor regarding Section 125 qualified cafeteria plans and other reimbursement accounts permitted by the Internal Revenue Code. The group's employer, not Oxford Benefit Management ("OBM"), shall remain the fiduciary for the Employer s flexible spending account and other reimbursement accounts permitted under the Code. Union employees Leased employees Part-time employees working less than hours per week Nonresident aliens Other: C. Waiting Period Date of Hire Date of Hire plus days or months Employees not eligible under employer's group medical plan 1

2 I I I. P R O D U C T S A. Check plans to be offered and enter maximum contribution levels: OxfordFlex Healthcare with Maximum Annual Contribution of $ Note:There is no IRS limit to OxfordFlex healthcare plan; the maximum contribution amount is up to the discretion of employer. The limits below are subject to change by the IRS. OxfordFlex Dependent Care: Maximum Annual Contribution of $ (not to exceed IRS maximum contribution limit) OxfordFlex Transit: Maximum Monthly Contribution of $ (not to exceed IRS maximum contribution limit) OxfordFlex Parking: Maximum Monthly Contribution of $ (not to exceed IRS maximum contribution limit) Please note: If an employer offers Oxford MyPlan to its employees, the OxfordFlex healthcare plan dollars must be exhausted before the Oxford MyPlan health reserve account can be made available to the employee. B. OxfordFlex Debit Card Yes (All eligible employees will receive up to two cards per family) No With debit card, we recommend employer maintain a 2 month minimum balance to offset point of sale debit card transactions. Note: If debit card is selected, the employer must complete the OxfordFlex Debit Card ACH Authorization Release Form.* With debit card, 25% of annual OxfordFlex healthcare contributions is required and 15% minimum weekly balance. Without debit card, 4% of annual OxfordFlex healthcare contributions is required. I V. F U N D I N G A N D D I S B U R S E M E N T A. Pay Periods Weekly (52 pay periods) Monthly (12 pay periods) 15th and last day of the month Other: B. Funding Options (Select either Option 1 or 2): Employers with less than 100 employees may only select option 2. Employers with 100 or more employees may select option 1 or 2. Option 1. Employer Maintains Employee Contributions in Employer's Bank (not available to Employers with < 100 employees). With debit card, we recommend employer maintain a 2 month minimum balance to offset point of sale debit card transactions. a. Manual claims disbursement frequency: 15th and last day of the month. b. For disbursement of funds for manual claims, please select one of the following: Oxford Benefit Management will draft checks off employer account to pay for incurred claims. Oxford Benefit Management will ACH funds for incurred claims from employer's bank account (Complete the OxfordFlex Claim Disbursement ACH Authorization Release Form).** Option 2. Employee contributions provided to Oxford Benefit Management on a pay-period basis: a. Pre-fund amount will be sent via: Hard copy check Wire transfer ACH*** b. Payroll deductions will be sent via: Hard copy check Wire transfer ACH*** c. Manual claims disbursement frequency: 15th and last day of the month. d. If additional funds are needed for OxfordFlex healthcare manual or debit card claims, the employer will fund via: Hard copy check Wire transfer ACH*** *Please complete the OxfordFlex Debit Card ACH Authorization Release Form (6700) to authorize MBI, our debit card vendor, to initiate ACH transfer entries. **Please complete the OxfordFlex Claim Disbursement ACH Authorization Release Form (6699) to authorize OBM to initiate ACH transfer entries.. ***Please complete the OxfordFlex Pre-Funding, Payroll Contribution and Manual Claims ACH Authorization Release Form (6701) to authorize Oxford Benefit Management to initiate ACH transfer entries. 2

3 C. Claim Reimbursement Deadline In 2005 the IRS passed a law to allow all FSA Healthcare; Dependant Care participants to encur and submit claims 2 1/2 months past the end of the plan year. It is up to the employer if they will allow this extended reimbursement period. Healthcare and Dependant Care deadline is the last day of the plan year Healthcare and Dependant Care deadline is 2 1/2 months past the end of the plan year V. B R O K E R / A G E N T I N F O R M A T I O N Broker Co-Broker General Agent 1. Name of Broker/Agent: 2. Oxford Broker Code (Required): 3. Social Security # or Federal Tax Id #: 4. Broker Street Address: 5. City, State, Zip: 6. Telephone Number: 7. Fax Number: 8. Address: 9. Oxford Sales Representative: Comments: Who will be Point of Contact during enrollment period: Employer Group Broker V I. N O N D I S C R I M I N A T I O N T E S T I N G Oxford Benefit Management will conduct nondiscrimination testing on your behalf at no extra charge. To be eligible for tax savings, cafeteria plans must not discriminate in favor of highly compensated employees (HCE) or key employees. A) A highly compensated emplooyee is defined as fitting into one or more of the following categories: a) All employees with more than a 5% ownership during the prior or current plan year; b) All employees who are a spouse or relative (within the meaning of IRC Section 318) of any individual listed in Part A above; or c) Employees earning more than $90,000 (indexed) in the prior plan year (An employer group may elect to treat as highly compensated under the $90,000 compensation test only those employees who are also in the top-paid 20% of the group) B) A key employee is defined as, at an tme during the current or the preceding plan year, fitting into one or more of the following categories: a) Officers with annual compensation greater than $130,000 (indexed) b) Employees with more than 4% ownership; or c) Employees with more than 1% ownership and annual compensation greater than $150,000 3

4 C) List of Highly-Compensated and Key Employees OxfordFlex SM performs a nondiscrimination test for the healthcare and dependent care products. The OxfordFlex Healthcare and OxfordFlex Dependent Care plans are only offered as part of a qualified Cafeteria Plan established under Section 125 of the Internal Revenue Code. Under the code, Cafeteria Plans are subject to certain nondiscrimination requirements which are intended to prevent plans from discriminating in favor of highly-compensated employees (HCEs) and key employees. Please provide a list of highly-compensated and/or key employees. Employee Name Please indicate whether employee is a highly-compensated or key employee 4

5 V I I. P L A N A D M I N I S T R A T I V E P R O C E S S E S A N D E L I G I B I L I T Y 1. The provisions in this application cover those Members enrolling in OxfordFlex plans. As set forth in this application, all eligibility rules and administrative information completed on this application for flexible benefits applies to all eligible employees. This application represents an agreement between OBM and the employer for the services described herein. The term of this application shall run for the period set forth in this application. 2. Employer agrees to pay OBM a coordination fee identified in the OxfordFlex rate quote for the services related to the coordination of the OxfordFlex account. Such fees shall be submitted to OBM on the first day of each calendar month during the term of this agreement. Failure to pay coordination fees or late payment is cause for termination by OBM as described in paragraph 3 of this section of this OxfordFlex Group Application. 3. This agreement may be terminated by either OBM or the employer upon at least sixty days prior written notice. This agreement may be immediately terminated by OBM if, (i) the employer fails to pay the administrative fee as described in paragraph 2; (ii) the employer fails to properly fund the OxfordFlex plan; (iii) the employer fails to follow other administrative procedures required by the Internal Revenue Code for the proper administration of the OxfordFlex plan. This agreement may be renewed for a subsequent one year term upon the submission and acceptance by OBM of a revised employer application at least thirty days prior to the expiration of the then current term. 4. The amount credited to a Member s OxfordFlex plan for any plan year shall be used only to reimburse the Member for qualifying OxfordFlex healthcare and OxfordFlex dependent care expenses incurred during such plan year while the employee was a Member, and only if the Member applies for reimbursement on or before the 90th day following the close of the plan year. 5. Assuming that the employer continues to provide the proper funding for the payment of eligible claims, upon termination of this agreement, OBM shall continue to process all claims that were incurred prior to termination, but not processed as of the date of termination ( run-off period ). All conditions of this agreement shall apply during the run-off Period. 6. Employer shall be responsible for the payment of all claims and all other administrative responsibilities associated with the OxfordFlex plan after the termination of this agreement. 7. OBM s administration of the OxfordFlex plans are subject to OBM s policies and procedures as modified by OBM from time to time. V I I I. P L A N C E R T I F I C A T I O N The undersigned employer hereby adopts and establishes the plan offering indicated above. The employer hereby appoints OBM as its ministerial agent to process claims under the OxfordFlex plans. OBM will at all times be subject to directions and instruction from the employer. The plan administrator is the employer. It shall be the principal duty of the employer, as benefits administrator, to see that the plan is carried out in accordance with its terms for the exclusive benefit of Members entitled to participate in the plan. Each eligible employee will have the opportunity to participate in the employersponsored OxfordFlex plan. Employer hereby agrees to offer the plan and benefits to all eligible employees. Said employer attests that the employee contributions to the OxfordFlex plans are provided to the employee on a tax-free basis. Employer certifies that the corporation has approved the offering of a qualified Section 125 cafeteria plan and /or transit and parking accounts and that the corporation will take actions as may be necessary to comply with this plan offering. As specified in section IV, employer agrees to pre-fund claims payments for claims on bi-weekly basis, or as otherwise required by OBM for the payment of eligible claims. The employer agrees to implement procedures for the reimbursement of improper claims submitted by Members, including (i) withholding amount of improper claims from Member's wages; (ii) offsetting amount of improper claims against further claims; or (iii) requiring Member to pay the employer the amount of improper claims. Employer agrees to indemnify and hold harmless OBM, its affiliates and their directors, officers, employees and agents against any and all losses, liability or damages, including reasonable attorney fees which OBM may incur by reason of employer's failure to properly fund, or substantiate claims applicable to the OxfordFlex accounts, or by the Member's failure to abide by the rules established for the OxfordFlex plans, or for any other disputes brought against OBM or an affiliate of OBM in connection with the services provided by OBM for the OxfordFlex plans. Employer acknowledges and agrees that OBM is not (i) the benefits administrator, or (ii) a fiduciary of the plan. X Signature of authorized officer of the company Date Title 5

CLIENT INFORMATION FORM - FLEXIBLE SPENDING ACCOUNTS

` CLIENT INFORMATION FORM - FLEXIBLE SPENDING ACCOUNTS Company Profile Legal Name of Organization: Broker of Record: Mailing Address: City: State: Zip: Executive Officer (signer): Email Address: Telephone: