SLETTO & ASSOCIATES, P - CHG Healthcare Services

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I.2. The Employer Credit(s) shall be limited for each eligible Participant … [check one and complete]: a. Not applicable [no limit] b. By an amount sufficient to fund Benefits selected c. Percentage [check one or more and enter percentage amount(s)]: i. Minimum: % of Plan Compensation ii. Maximum: % of Plan Compensation d. Dollar [check one or more and enter dollar amount(s)] : i. Minimum: $ of Compensation ii. Maximum: $ of Compensation e. Percentage/Dollar [check one or more and enter dollar amount(s)]: i. Minimum: % of Plan Compensation or $ of Compensation ii. Maximum: % of Plan Compensation or $ of Compensation f. Other [specify]: I.3. The Employer Credit period applicable to Item I.1. and I.2. is as follows…[check one]: a. Payroll period b. Month c. Plan Year quarter d. Plan Year half e. Other [specify]: I.4. The Employer Credit(s) shall be submitted pro-rata each… [check one]: a. Pay period b. Month d. Plan Year quarter d. Plan Year half e. Other [specify]: Allocation Requirements: [Plan Sec. 5.4] I.5. To be eligible to receive an Employer Credit allocation for a Plan Year, the Participant must… [check one]: a. Not applicable [all Participants are eligible] b. Other [specify]: J. Insurance Premium Conversion Insurance Premium Conversion: [Plan Sec. 6.1] Dependent Coverage: [Plan Sec. 7.1] J.1. J.2. The following Insurance Benefits are available for payment through the Plan on a pre-tax basis… [check one]: a. N/A - Spending Accounts only [skip to Item J.2.] b. Accident or Health Insurance [IRC Section 106] i. Health Care ii. Accidental Death or Dismemberment iii. Dental Care iv. Vision Care v. Long-Term Disability vi. Other [specify]: c. Group-Term Life Insurance [IRC Section 79] d. Other [specify] : Dependent coverage may be elected by the Participant for… [check one]: a. Not applicable [only Participant coverage allowed] b. Health Care c. Accidental Death or Dismemberment d. Dental Care e. Vision Care f. Long-Term Disability g. Group-Term Life Insurance h. Other [specify] : ____________ J.3. ADOPTION AGREEMENT Participants may, at the discretion of the Administrator, obtain individual policies for the following Insurance Benefits… [check one]: 8 FLEXIBLE BENFITS PLAN
a. Not applicable [no individual policies will be allowed] b. Health Care c. Dental Care d. Vision Care e. Long-Term Disability f. Other [specify] : J.4. In addition to legal limits, if any, Insurance Benefits will be limited as follows… [check one]: a. N/A [no additional limits] b. Other [Note: Group Term Life Insurance coverage over $50,000 of death benefit may result in taxation to the Participant.] K. Spending Accounts Spending Accounts: [Plan Sec. 6.2] K.1. Spending Accounts will be established for… [check one]: a. N/A [Insurance Premium Conversion only - skip to Item L.] b. Medical Reimbursement Expense [IRC Section 106] c. Dependent Care [IRC Section 129] d. Adoption Assistance [IRC Section 137] e. Health Savings Account [IRC Section 223] d. 401(k) [IRC Section 401(k)] e. Paid Time Off f. Cash Payments g. Other [specify; must not provide benefits which are prohibited under Prop. Reg. 1.125-1(q)]: K.2. In addition to legal limits, if any, Spending Accounts will be limited as follows… [check one]: a. N/A [no additional limits] b. Medical Reimbursement Expense [IRC Section 106] i. N/A [no additional limits] ii. Other [specify]: $5,000 c. Dependent Care [IRC Section 129] i N/A [no additional limits] ii. Other [specify]: d. Adoption Assistance [IRC Section 137] i. N/A [no additional limits] ii. Other [specify]: d. 401(k) [IRC Section 401(k)] i N/A [no additional limits] ii. Other [specify]: e. Paid Time Off i N/A [no additional limits] ii. Other [specify]: f. Cash Payments i N/A [no additional limits] ii. Other [specify]: g. Other [specify]: Note: Even if no limit is specified by the Sponsoring Employer, the applicable legal limits to maintain the tax-qualified status of the applicable Benefit shall apply. K.3. For Medical Reimbursement Expense Account reimbursements, new elections due to a Change In Status are: [check one]: a. Not applicable [Benefit not allowed] b. Not permitted c. Permitted without limitation d. Permitted, but only to increase Benefit elections e. Permitted, but not lower than the net amount of claims as of the election date f. Other [specify]: ADOPTION AGREEMENT 9 FLEXIBLE BENFITS PLAN
Page 1 and 2: BENEFITS AND BUSINESS LAW ADVISORS,
Page 3 and 4: Plan Administrator: [Plan Secs. 1.1
Page 5 and 6: ii. iii. iv. Employees employed as
Page 7: G.5. Participants will be automatic
Page 11 and 12: L. COBRA Elections COBRA Elections:

SLETTO & ASSOCIATES, P - CHG Healthcare Services

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