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10.19(a) Grandfathered Status: <br /> ❑ The Plan is a grandfathered plan <br /> ® The Plan is not a grandfathered plan <br /> 10.19(c) The Plan is a HIPAA excepted benefit ❑ Yes ® No <br /> ACKNOWLEDGEMENTS <br /> 1. Pursuant to Section 2.10(b) of the Basic Plan Document, any collectively bargained Employees <br /> participating in this Plan participate because the collective bargaining agreement provides for <br /> coverage under this Plan. <br /> 2. This Plan has been duly adopted or authorized to be adopted by the Adopting Employer. <br /> 3. This Plan is a"covered entity"for purposes of the Privacy Rules under the Health Insurance <br /> Portability and Accountability Act(HIPAA). <br /> ADOPTING EMPLOYER: City of Everett <br /> Grant agreement between Benefit Plans Administrative Services, LLC("BPAS") and Hand Benefits & <br /> Trust (HB&T) and the City of Everett. <br /> CITY OF EVERETT: <br /> Date: <br /> 't5C/ <br /> Mayor <br /> ATTEST: <br /> Date: <br /> fix' , City Clerk <br /> Office of the City Attorney <br /> APPROVED AS TO FORM <br /> Date: yi o20 �/J <br /> David C. Hall, City Attorney <br /> City Attorney <br /> ©Copyright 2017 Hitesman&Wold, P.A. Page 7 <br /> HRA Basic Plan Document Adoption Agreement(Single Employer Non-ERISA) <br />