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FUNDED HEALTH REIMBURSEMENT ARRANGEMENT <br /> BASIC PLAN DOCUMENT <br /> ADOPTION AGREEMENT <br /> This is the Adoption Agreement referred to in the Funded Health Reimbursement Arrangement <br /> Basic Plan Document (Single Employer Non-ERISA) (the "Basic Plan Document"). This Adoption <br /> Agreement plus the Basic Plan Document, as amended from time to time, constitutes the Plan. <br /> ADOPTING EMPLOYER INFORMATION: <br /> Name: City of Everett <br /> Address: 2930 Wetmore Ave Suite 5-A <br /> City, State Zip: Everett, WA 98201 <br /> Federal ID # 91-6001248 <br /> Trust EIN # 83-6346037 <br /> MISCELLANEOUS: <br /> Addendum(s) Attached: ❑ Yes ❑ No <br /> ARTICLE I: INTRODUCTION <br /> 1.1 Original Effective Date: January 01, 2019 <br /> (month,day,year) <br /> Effective Date of Restatement: N/A <br /> (month,day,year) <br /> ARTICLE II: DEFINITIONS <br /> 2.9 Dependent means: <br /> ® "Dependent"means an individual (other than the Participant and the Participant's <br /> Spouse) with respect to whom amounts expended for medical care are excluded <br /> from the Participant's gross income under Section 105(b) of the Code, as amended. <br /> ❑ Other (Describe): <br /> 2.12 Entry Date means: <br /> ® Date Employee becomes eligible to participate. <br /> ❑ Other (Describe): <br /> 2.16 Health Care Expense means: <br /> ® Maximum permitted by law (i.e., Section 213(d) medical expenses). <br /> ❑ Only expenses eligible for deductible &OOP credit under the following group medical <br /> plan: <br /> ❑ Only expenses for dental and vision care that qualify as Section 213(d) medical <br /> expenses, as modified by Section 106(f). <br /> ❑ Other <br /> ©Copyright 2017 Hitesman&Wold, P.A. Page 1 <br /> HRA Basic Plan Document Adoption Agreement(Single Employer Non-ERISA) <br />