EMPLOYER ADOPTION AGREEMENT FOR THE INDIANA MANUFACTURERS ASSOCIATION GROUP INSURANCE TRUST

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1 EMPLOYER ADOPTION AGREEMENT FOR THE INDIANA MANUFACTURERS ASSOCIATION GROUP INSURANCE TRUST ( Employer ) and, if applicable, the Affiliated Employers hereby request participation in the Indiana Manufacturers Association Group Insurance Trust ( Trust ), and acknowledge and agree to the following: I. Affiliated Employers a) Definition of Affiliated Employers. If the Employer owns at least 80% of another entity, or another entity owns at least 80% of the Employer; or if the same five or fewer persons or entities own at least 80% of the Employer and at least 80% of other entities; or if the Employer has an ownership interest in an entity that regularly provides services to the Employer or to others in coordination with the Employer; or a service business derives a significant portion of its business from performing services for the Employer, then the owner of the Employer, or the attorney or accountant for the Employer shall determine whether the Employer and any of these entities should be treated as one entity for purposes of participation in the Trust. b) Statement of Affiliated Employer Status. [Choose one of either i) or ii)] i) The Employer is not a member of a parent-subsidiary controlled group or a brother-sister controlled group or an affiliated service group of companies under the Internal Revenue Code, and it therefore has no Affiliated Employers. OR ii) The Employer is a member of a parent-subsidiary controlled group or brother-sister controlled group or an affiliated service group of companies under the Internal Revenue Code ( Affiliated Employers ), and it therefore has Affiliated Employers. The owner, attorney or accountant of the Employer must complete the Affiliated Employer Certification in Appendix A. c) Signature Requirements. The Employer and each Affiliated Employer must sign this Adoption Agreement. II. Adoption Agreement a) Adoption. In consideration of the benefits provided by the Trust to the employees, and/or retirees and/or directors of the Employer and its Affiliated Employers (collectively, Employees ) and their spouses and children ( Beneficiaries ), the Employer and Affiliated Employers hereby join, or continue their participation in the Trust and agree to be bound by the terms of the Trust, the insurance policies purchased by or issued to the Trust, and the rules and regulations adopted by the Plan Administrator of the Trust or Trustees for administration of the Trust, as they exist now and in the future. 1

2 b) Effective Date. This Adoption Agreement shall be effective upon signature by the Employer and all Affiliated Employers and written acceptance by the Plan Administrator. III. Employer Eligibility, Withdrawal and Termination a) Membership in Indiana Manufacturers Association. The Employer and all Affiliated Employers certify that they are a regular member in good standing of the Indiana Manufacturers Association (the Association ), and that they will remain a member so long as they participate in the Trust. Failure to remain a regular member in good standing of the Association will result in cancellation of coverage through the Trust effective on the last day of the first month which is 30 days after the failure. b) Withdrawal From Trust. The Employer may withdraw from the Trust by giving at least 30 days advance written notice to the Plan Administrator. The withdrawal will become effective on the last day of the month which is more than 30 days after the notice is received by the Plan Administrator. For instance, if the Employer gave notice of withdrawal on July 3, the Employer s withdrawal would become effective at the end of the day on August 31. The Employer would have to pay all amounts that were owed to the Trust through August 31. The Employer and Affiliated Employers must at all times meet the minimum participation requirements in Section II(b) above. If the Employer withdraws, then all Affiliated Employers must also withdraw. c) Termination of Participation. The Plan Administrator may cancel some or all of an Employer s or Affiliated Employer s coverages prospectively or retroactively to the full extent permitted by law in the event of non-payment of premiums, failure to meet benefit, participation or eligibility requirements, failure of the Employer to maintain status as a regular member in good standing of the Association, repeated violations of the Trust, the insurance policies and/or the rules and regulations adopted by the Plan Administrator or Trustees for administration of the Trust, fraud or the intentional misrepresentation of a material fact. If an Employer s or Affiliated Employer s participation is terminated by the Plan Administrator, the Employees and Beneficiaries of the Employer or Affiliated Employer may not be eligible for COBRA coverage. IV. Election of Benefits, Eligibility Rules and Plan Year a) Eligibility Requirements. The Employer and Affiliated Employers acknowledge that the eligibility of their Employees and Beneficiaries for Trust benefits, their entry into Trust benefits and their loss of Trust benefits are based upon rules established by the insurance carriers that provide coverage to Employees and Beneficiaries through the Trust ( Insurance Carriers ) and by the Plan Administrator, such as minimum hours requirements, actively at work requirements and minimum participation requirements. The Employer and all Affiliated Employers agree to comply with all such requirements. b) Benefit Elections. The Employer and Affiliated Employers may offer to their Employees and Beneficiaries any or all of the Trust benefits for which the Employer or Affiliated Employers are eligible ( Benefit Elections ). 2

3 c) Eligibility Rules. The Employer and Affiliated Employers may select eligibility and entry rules, such as hours of service requirements, waiting periods, and elimination periods, as permitted by law, by the Trust, and by the Insurance Carriers ( Eligibility Rules ). d) Reporting and Changing Elections. The Employer and Affiliated Employers will report their Benefit Elections and Eligibility Rules to the Plan Administrator and/or to the Insurance Carrier(s), and will change their elections only as permitted by the Insurance Carriers and Plan Administrator. They will promptly report any permissible changes in Benefit Elections or Eligibility Rules on forms provided by the Plan Administrator and/or the applicable Insurance Carrier. The Employer and Affiliated Employers will provide all information reasonably requested by the Plan Administrator or Insurance Carriers in connection with their Benefit Elections and Eligibility Rules. e) Eligibility Certification. The Employer and Affiliated Employers certify that they will only submit Employees and Beneficiaries for coverage who are eligible for coverage, and that the information they provide to the Trust about whom they employ, including but not limited to their hire and termination dates, their hours of work, their classification and their compensation, will be complete and accurate, and will be promptly revised so that the information remains complete and accurate. f) Waiver Restrictions. The Employer and Affiliated Employers agree that they will not waive the Eligibility Rules, such as waiting periods, elimination periods, minimum hours, participation requirements or actively at work requirements that they have reported to the Trust and/or the Insurance Carriers, except with the written permission of the Plan Administrator and/or the Insurance Carrier(s). g) Legal Compliance. The Employer and Affiliated Employers will consult with and rely on only their own attorney and consultants to determine whether their Benefit Elections and Eligibility Rules comply with all applicable laws, such as ERISA and the Internal Revenue Code, and applicable non-discrimination rules. h) Plan Year. The Employer and Affiliated Employers will elect a Plan Year on forms provided by the Trust and/or an Insurance Carrier. V. Premiums a) Premium and Cost Determinations and Allocations. The Employer and Affiliated Employers acknowledge that the Plan Administrator has the absolute right, in consultation with the Insurance Carriers, to set and amend the Insurance Carrier premiums and the administrative costs ( Premiums and Costs ) to be paid by them for participation in the Trust, and to allocate the Premiums and Costs among the Employers and Affiliated Employers, as the Plan Administrator deems helpful, necessary or appropriate. b) Payment. The Employer and Affiliated Employers will pay all Premiums and Costs promptly to the Trust, and they understand that coverage for their Employees and Beneficiaries will be terminated, in some cases retroactively, if they fail to timely 3

4 pay Premiums and Costs. The Plan Administrator may, in its sole discretion, provide a grace period for payment of Premiums and Costs. c) Split of Premiums and Costs With Employees. The Employer and Affiliated Employers may split the Premiums and Costs with their employees as permitted by the Plan Administrator and the applicable Insurance Carriers. The Employer and Affiliated Employers must report the split to the Plan Administrator and/or Insurance Carriers, and must promptly advise the Plan Administrator and applicable Insurance Carrier if they change the split of Premiums or Costs. At the present time, the insurance carrier generally requires the Employer and Affiliated Employers to pay at least 25 percent of the total cost for health coverage in the event an Employee has dependent coverage, and at least 50 percent of the total cost for health coverage in the event an Employee has single coverage. d) Refund of Premiums or Costs. If the Employer or an Affiliated Employer pays Premiums and Costs for persons who are not eligible for coverage, the Trust will only refund the Premiums or Costs to the Employer or Affiliated Employer to the extent the Insurance Carrier refunds or provides a credit to the Trust for the Premiums and to the extent the Trust has not already provided services related to the Costs. VI. Notice and Document Distribution Requirements The Employer and Affiliated Employers will distribute to Employees and Beneficiaries all documents that are provided by the Plan Administrator, as requested by the Plan Administrator, including but not limited to, Summary Plan Descriptions, Summary Annual Reports and annual and periodic notices. VII. COBRA Requirements The Employer and Affiliated Employers are solely responsible for timely providing notice to the Plan Administrator regarding the hire of a new Employee, the divorce of an Employee, the legal separation of an Employee, the death of an Employee, an Employee s termination of employment, an Employee s reduction in hours and a child s no longer meeting the eligibility requirements of the Plan ( COBRA Qualifying Events ). When notice is provided by the Employer or an Affiliated Employer to the Plan Administrator of a COBRA Qualifying Event, the Plan Administrator shall provide COBRA notices to the Employee and Beneficiaries. VIII. Indemnification of the Association, Trust, Trustees, Plan Administrator and Agents The Association, the Plan Administrator, the Trustees and their agents are not providing legal advice or recommendations to any Employer or Affiliated Employer. The Employer and Affiliated Employers shall indemnify the Association, the Trust, the Trustees, the Plan Administrator and their agents against any and all liabilities, damages and costs, including attorney fees and expenses, paid or incurred by the Association, the Trust, the Trustees, the Plan Administrator or their agents that arise from coverage of ineligible persons or the Employer s or an Affiliated Employer s administration of any Trust benefit, such as a violation of a non-discrimination rule or the 4

5 Notice Requirements under Section VI above or COBRA requirements under Section VII above. IN WITNESS WHEREOF, the undersigned Employer executes this Adoption Agreement on, 20. Affiliated Employers: Name of Employer Name and Title of Authorized Person Signature of Authorized Person Name of Entity: Signature of Authorized Person: Name of Entity: Signature of Authorized Person: Name of Entity: Signature of Authorized Person: Accepted by the Plan Administrator this day of, 20. Plan Administrator This Adoption Agreement is required by law, and the signed Agreement must be returned to the Plan Administrator of the Trust: Attention: Plan Administrator Indiana Manufacturers Association Group Insurance Trust 2400 One American Square Box Indianapolis, IN

6 APPENDIX A AFFILIATED EMPLOYER CERTIFICATION As described in Section I of the Employer Adoption Agreement, all entities treated as a single employer under Sections 414(b), (c), (m) or (o) of the Internal Revenue Code are considered one employer for purposes of the minimum participation requirements set out in Section II(b) of the Employer Adoption Agreement. Please list below all Affiliated Employers that qualify as one employer under the Internal Revenue Code. Name of Entity Employer Federal Tax Identification Number [FEIN] I certify that the above-listed business entities are considered as one employer under Section 414 of the Internal Revenue Code. Date: Signature: Please check one of the following: Owner of Employer Accountant for the Employer Attorney for the Employer 6

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