Ronald McDonald House Charities Health & Welfare Plan Wrap Document Adoption Agreement California and Minnesota

Transcription

1 Charity Name: Charity Address: By completion of this Adoption Agreement, effective, the Charity adopts the Ronald McDonald House Charities Health & Welfare Plan Wrap Document ( Plan ), pursuant to the terms set forth in this Adoption Agreement. The provisions of the Plan established hereunder shall include the Plan, the elections on this Adoption Agreement and the provisions of any applicable Insurance Benefit Agreement or administrative services contract. You may make elections in the following categories under this Adoption Agreement, which serve to modify the default provisions of the Plan. You may only modify those options listed below. All other elections or modifications will be void. Should you not make an election; the default provision of the Plan will apply. I. ELIGIBLE EMPLOYEES All active, full-time salaried employees of a Charity and established for a nonprofit corporation who meet the following requirements will be Eligible Employees. JOB CLASSIFICATION Employees in the following job classes: (you may elect one or more of the following job classes.) 1. Senior Management Position (ED, CEO) 2. House Manager 3. Directors (Financial, Marketing, Development) 4. House Administrative / Clerical Support 5. Security / Housekeeping 6. Other House Position Default Option: All Job Classifications AGE: 18 and over HOURS WORKED Employees who normally work the following number of hours per week or more hours or more 30 hours or more Default Option: 17.5 or more SERVICE REQUIREMENT (Eligibility Period) Employees who have completed the following period of service: (You may elect more than one) Immediate coverage for One calendar month for Three calendar months for Six calendar months for One year for all classes or Class(es) all classes or Class(es) Default Option: Immediate for all classes

2 II. BENEFIT OPTIONS Choose the Benefit Option(s) you will offer to all employees that meet the eligibility requirements you selected in Section I. Your employer contributions to the cost of coverage for the various Classes can be identified on the Monthly Premium Payment Schedule in Section III. BASIC COVERAGE: I DO NOT qualify for the Blue Cross and Blue Shield of Illinois Medical Plan because my organization falls within the state s small employer definition. I DO qualify for the Blue Cross and Blue Shield of Illinois Medical Plan and choose the following: BASIC TERM LIFE / AD&D TRAVEL ACCIDENT / MEDICAL: offered not offered MHC 250 MHC 500 MHC 1,000 MHC 5,000 MHC 10,000 HDHP 2,000 Default Option: All coverages offered OPTIONAL COVERAGE: BASIC TERM LIFE / AD&D TRAVEL ACCIDENT: offered not offered SUPPLEMENTAL TERM LIFE / AD&D: offered not offered DENTAL: offered not offered VISION: offered not offered SHORT TERM DISABILTY: offered not offered LONG TERM DISABILITY: offered not offered

3 III. MONTHLY PREMIUM PAYMENT SCHEDULE Indicate your contributions, if any, to the premium. Use more than one schedule if contribution varies by Class of employee. This schedule applies to all job classifications or Class Charity pays the dollar amount or percentage listed below: BASIC TERM LIFE / AD&D / TRAVEL ACCIDENT / MEDICAL: DENTAL: VISION:

4 MONTHLY PREMIUM PAYMENT SCHEDULE (continued) Indicate your contributions, if any, to the premium. Use more than one schedule if contribution varies by Class of employee. This schedule applies to all job classifications or Class Charity pays the dollar amount or percentage listed below: BASIC TERM LIFE / AD&D / TRAVEL ACCIDENT ONLY: (complete only if no medical coverage is elected above) SUPPLEMENTAL TERM LIFE / AD&D: COVERAGE MUST BE 100% EMPLOYEE PAID SHORT TERM DISABILITY (CORE): SHORT TERM DISABILITY (BUY-UP): LONG TERM DISABILITY: IV. The Charity should be aware that this is a standardized Adoption Agreement used to modify the default participation options in adopting the Plan. By completing this Adoption Agreement, the Charity acknowledges and agrees to discharge all of the duties and responsibilities as a Participating Employer as set forth in the Plan, those set forth in the Plan Administration Manual, or as may otherwise be assigned to the Charity by the Plan Administrator. Because participating in the Plan involves important legal and tax considerations, you should seek the advice of counsel. The undersigned hereby acknowledges the adoption of the Ronald McDonald House Charities Health & Welfare Plan Wrap Document, as amended by this Adoption Agreement.

5 V. The provisions of the plan as adopted by a Charity in the Adoption Agreement include the Ronald McDonald House Charities Health & Welfare Plan Wrap Document ( Plan ) Only Eligible Employees as defined in the Plan and limited by a Charity in its Adoption Agreement are eligible to participate in the Plan. It is the Plan s position that all Eligible Employees must be, or must have been, common law employees of a Charity. An individual is a common law employee for this purpose only if the Charity: pays the individual cash wages; treats the individual as an employee for state and federal income and employment tax withholding and reporting purposes; and treats the individual as an employee for purposes of applicable labor laws. Although an individual must satisfy all of the above requirements in order to be considered a common law employee for purposes of the Plan, the fact that an individual satisfies all of the above requirements is not conclusive or binding on the Plan that the individual is a common law employee. The Plan conducts an annual audit to ensure that only Eligible Employees are participating in the Plan. If it is discovered that a Charity has allowed an individual who is not an Eligible Employee to participate in the Plan, the Charity will be expected to reimburse the Plan for any amount paid to or on behalf of such individual. In addition, if a Charity fails to permit the annual eligibility audit, fails to provide requested information, and/or engages in fraud or intentionally misrepresents material facts in connection with the administration of the plan, including whether an individual is an Eligible Employee, the Charity s (and therefore its employees ) participation in the Plan may be terminated and the Charity may be barred from future participation in the Plan. Please check below if you intend to maintain grandfather status for the 2011 plan year under the Ronald McDonald House Charities Health & Welfare Plan: Yes, I intend to maintain grandfather status No, I do not intend to maintain grandfather status Name of Charity By: Executive Director / Board Member Signature Date: Phone Number: ( ) - Fax Number: ( ) - Address: Attest: Corporate Secretary signature if applicable