The URL can be used to link to this page

Home My WebLink AboutI - 03 Safe Harbor Health Total Wellness Program The Total Wellness Program An Innovative Wellness Program Town of Cortlandville Estimated Proposal Safe Harbor Health 80 Washington Square Building Q58 Norwell, MA 02061 Thank you for considering Safe Harbor’s Total Wellness Program. Please be sure to review the benefits and program offering carefully because we have made significant upgrades to our platform. For further details, check out the Product section of our website at www.safeharborsavings.com. Provided in this proposal is your request for pricing for Town of Cortlandville. Based on the census data provided, please find an estimated quote prepared for an effective date of 12/01/2023. If you have any questions, please feel free to speak to your representative. Beyond great coverage, we also offer tools and support to help you manage your plans. With Enrollment Management, you can add subscribers and dependents, update information, and change coverage. We appreciate this opportunity and are pleased that you have considered The Total Wellness Program Sincerely, The Safe Harbor Team Total Wellness Program By the numbers. An Estimate for Town of Cortlandville Eligible Employees 42 Estimated Employer Yearly Tax Savings $23,780.25 Estimated Yearly Employer Tax Savings Per Employee $566.20 Total Estimated Employee Yearly Tax Savings $79,627.34 Estimated Yearly Tax Savings For Each Employee $1,895.89 Employee Estimated Monthly Available funds for spend $157.99 i EMPLOYER PROGRAM ADOPTION AGREEMENTS - WELLNESS PROGRAM - SECTION 125 - SELF -INSURED MEDICAL EXPENSE REIMBURSEMENT PLAN EMPLOYER INFORMATION FORM Below is the required company information needed for the adoption of the Wellness Program, Section 125 Plan, and the Self -Insured Medical Expense Reimbursement Plan (SIMERP), as applicable. To enact each plan named herein, an authorized Company official must execute the respective Adoption Agreement. COMPANY CONTACT: Name: 1v V d(�'�150� Title:�� 2 5TY`a[7 C7V Phone: (L o7) 75 & . sm5_ Email: W '17ti ohn(oIvrll� COMPANY INFO: NAME ::j&kj-62F 1 Akt.6 V I UV MAILING ADDRESS -�- _-j 'fgg4rAo.rs CITY l dMIV4- T) STATE ZIP CODE 3d ! EMAIL I� [e • wq PHONE NUMBER LEGAL STATUS: (please check one) O C Corporation Q S Corporation 0 LLP Partnership Q Non -Profit 0 Sole Proprietor Q Other STATE OF ORGANIZATION EMPLOYER IDENTIFICATION NUMBER /ElN# Rom O LLC 1S Government Agency Safe Harbor Copyright 2020 RevHGS COMPANY OFFICERS - COMPANY OWNERSHIP — please include % ownership Calendar Year 1. The Plan Sponsor is a member of an affiliated service group: OYes *No If Yes, please list all members of the group (other than the Plan Sponsor) 2. Is the Plan Sponsor a member of a controlled group? 0Yes •No If Yes, please list all members of the group (other than the plan sponsor) EXISTING PRE-TAX EMPLOYER SPONSORED PLANS: f� 1. Select the programs you currently sponsor that are pre -taxed. �! O Wellness Program Q Medical Reimbursement Plan Vision p Short -Term Disability Q Long -Term Disability Q Accident Insurance Q Health Savings Account Q COBRA Administration Dental 0Other 9EAAV4 5G �� U(5101� 2. Do you have an existing Section 125 Cafeteria Plan in place for any of these benefits? • Yes O No If Yes, current Plan will be Amended and Restated. If No, a new Cafeteria Plan under Code Section 125 must be established. 3. Do any of your programs serve 100+ employees? Q Yes 0 No 4. Do you currently file form 5500? OYeseNo Safe Harbor Copyright 2020 RevHG5 PROGRAM INFORMATION The Employer is the Plan Sponsor for the program. The Employer is the Plan Administrator for the program. Program Effective Date: 01 D Z Plan Year: 0 1 10-L-__ THE FOLLOWING SHALL GOVERN ALL ELIGIBLE MEMBERS OF THE PROGRAM: 1. All eligible Employees will become immediately eligible for the initial Program Effective Date. 2. Employees may also become eligible the first of the month following satisfaction of the Minimum Age and Minimum Service Requirements. 3. Employees shall be terminated from the program when employment ceases; or when they become otherwise ineligible to participate. 4. If not currently in place, Automatic Enrollment in a qualifying Section 125 plan is required. 5. Participant Contribution amounts will be automatically adjusted for changes in the cost of the Employer sponsored Contracts and Eligible Employees may make plan changes/termination requests pursuant to the terms of Treasury Regulation 1.125-4. EMPLOYEES THAT ARE NOT ELIGIBLE: 1. The Employee is NOT covered by an employer Sponsored Medical Plan (can be spouse/parent plans) 2. The Employee is working as a Non W2, Independent Contractor, Seasonal/Temporary, Intern. 3. The Employee is a Non -Resident Alien - Any Employee who is a non-resident alien cannot participate. 4. The following exclusions for teased Employees will be designated: A. Part-time employee who is expected to work less than 20 hours per week B. Union if there is no provision in the collective bargaining agreement The Self -Insured Medical Expense Reimbursement (SIMERP) Account allows a maximum annual amount to be credited: Eligible Employee: $9,600 per year Eligible Employee w/ Dependent(s): $13,500 per year PROGRAM BENEFITS: Eligible reimbursement shall include qualified medical expenses defined under the Company Wellness Plan pursuant to section 213(D) of the IRC. Safe Harbor Copyright 2020 RevHG5 I IIllAN �lwomiu.IImL11111 111111 111 111 111 1L1 I IIII I1 IN 1111 11 1 11 1 Covered person(s) shall include the eligible employee, their spouse and all dependent children) up to their 241" Birthday, as defined by Code section 152 as modified by Code section 105(b), and any child as defined in section 152(f)(1). EMPLOYER APPROVAL/COMPLIANCE Failure to complete this Addendum A may result in the failure of the Plan(s) to achieve the intended tax consequences. I hereby acknowledge that the information contained in this Addendum is complete and accurate to the best of my knowledge. I am aware that additional fees will apply if the information in these documents must be redrafted later. In order to make the Program effective, all portions of the agreement must be completed. The Program shall consist of: A. The Adoption Agreement B. Addendum A to the Adoption Agreement C. Basic Plan Document D. Any related Appendices. _ REQUIREMENTS FOR PROGRAM DOCUMENTATION & ELIGIBILITY An Employee's eligibility for participation in the plans may be affected by the following: 1. Employee must meet Minimum Age Requirements (for insurance products) 2. Employee must meet Minimum Service Requirement 3. Employee will be deemed "Eligible" the 11 of the month following completion of requirements 1&2. 4. The Plan may not discriminate in favor of highly compensated employees. (see Code section 105(h)(5)) as to benefits provided or eligibility to participate) I, as an authorized representative of indicate that I have read and agree with the information provided herein. I am also aware that additional legal documents will be prepared to fulfill the adoption of the Program. Signatures to execute this agreement ny [Client] [Printed Name] [Authorized Signature] Date: Safe Harbor Copyright 2020 RevHG5 �IIIW r IOW limp nommm I ■ iI III Date: Company Name: Company Address: T'. SAFE HARBOR H t A I r H 40cvXr or C0X7k+9b01tLt :d 36T? -RXAAeL T-VAP , COM07VO A`/ Please accept this letter authorizing Yn U-0-4 qo*�5-04 to share all required payroll and personhel data required to complete the Safe Harbor Census ASAP. I further authorize my broker, lFjti 6RvaT>, ue- as well as The Safe Harbor Compliance Team to request and collect additional payroll information (Quarterly Tax Fillings/New Employee Information) as needed to confirm compliance to the Medical Expense Reimbursement Plan requirements. ve Authorized Employer Signature Printed Name Safe Harbor Health / TOTAL Wellness Program 80 Washington Street, Building Q58 Norwell, MA 02061 800-503-6751 / info@SafeHarborSavings.com