Community Trust & Investment Instructions:

Transcription

1 Community Trust & Investment Instructions: If you have questions completing this form, please contact BDG Benefits Design Group, Inc. Health Savings Account (HSA) Enrollment Form and Agreements Mail/Deliver the following to: P. O. BOX Plano, TX Enrollment Form (Pages 1 and 2) Adoption Agreement (Page 5) BDG Benefits Design Group, Inc. FOR INTERNAL TPA USE ONLY Keep the following for your records: Health Savings Account Custodial Agreement (Pages 6-9) Account Holder and Dependent Information: TITLE NAME (FIRST, MIDDLE, LAST) DATE OF BIRTH SOCIAL SECURITY NUMBER MR. MRS. MS. DR. STREET ADDRESS, CITY, STATE, ZIP CODE MAILING ADDRESS (IF DIFFERENT FROM ABOVE) TELEPHONE NUMBER (DAY) TELEPHONE NUMBER (EVENING) ADDRESS ( ) ( ) SPOUSE NAME (FIRST, MIDDLE, LAST) SPOUSE ADDRESS (IF DIFFERENT FROM ABOVE) DEPENDENT NAME (FIRST, MIDDLE, LAST) DEPENDENT NAME (FIRST, MIDDLE, LAST) DEPENDENT NAME (FIRST, MIDDLE, LAST) Initial Contribution: IS THIS A ROLLOVER? YES NO AMOUNT OF ROLLOVER CONTRIBUTION In the case of a rollover from an HSA, I certify that this contribution is a rollover contribution within the meaning of Internal Revenue code Section 220, that the rollover is being made within 60 days of receipt and I have not received a rollover in the last 12 months. Contributions: Maximum contribution for 2014 to your HSA is $3,300 for individual coverage or $6,550 for family coverage. A) ANNUAL DEDUCTIBLE AMOUNT OF HIGH-DEDUCTIBLE HEALTH PLAN FOR SINGLE FAMILY COVERAGE... $ B) MONTHLY CONTRIBUTION FOR YEAR $ C)ANNUAL CONTRIBUTION FOR YEAR $ IMPORTANT: IF YOU ARE AGE 55 OR OLDER, YOU MAY BE ABLE TO MAKE ADDITIONAL CATCH-UP CONTRIBUTIONS TO YOUR HSA BEYOND WHAT IS SHOWN BY THE ABOVE CALCULATION. 1

2 Beneficiary Designation: I hereby direct that if I die before distribution has been completed, the value of my account shall be distributed to the person(s) named below: Primary Beneficiary (ies) NAME ADDRESS RELATIONSHIP SOC. SEC. NO. DATE OF BIRTH PERCENTAGE TOTAL MUST EQUAL 100 Contingent Beneficiary (ies) NAME ADDRESS RELATIONSHIP SOC. SEC. NO. DATE OF BIRTH PERCENTAGE TOTAL MUST EQUAL 100 The funds remaining in the HSA at my death shall be paid in the percentages indicated above (or in equal shares if no percentages are provided) to the Primary Beneficiaries who survive me. If a Primary Beneficiary predeceases me, the interest of the deceased Primary Beneficiary shall terminate and the percentage share of any surviving Primary Beneficiary(ies) shall increase on a pro rata basis. If no Primary Beneficiary survives me, the payment shall be paid in the percentages indicated above (or in equal shares if no percentages are provided) to the Secondary Beneficiaries who survive me. If a Secondary Beneficiary predeceases me, the interest of the deceased Secondary Beneficiary shall terminate and the percentage share of any surviving Secondary Beneficiary(ies) shall increase on a pro rata basis. If my spouse receives the HSA as a result of being named as Beneficiary and the Custodian consents, my spouse may choose to continue the HSA in his or her name by providing a written election to the Custodian and by signing the forms and providing the information that the Custodian requires. For any non-spouse Beneficiary, the HSA terminates as of my date of death and becomes payable. If no Beneficiaries are named on this form or if all of the named Beneficiaries predecease me, the HSA funds will be paid to my estate. I may change my Beneficiary(ies) by filing a new Beneficiary Designation in a written form acceptable to the Custodian prior to my death. I understand that in certain states my spouse s consent may be necessary if I wish to name a person other than, or in addition to, my spouse as Beneficiary, and that I should consult with my attorney before making such a Beneficiary Designation. By making the foregoing Beneficiary Designation, I represent and warrant to the Custodian that said Beneficiary Designation satisfies all legal requirements under applicable law and, on behalf of myself, the Beneficiaries, my heirs and my estate, I hereby indemnify and hold the Custodian harmless from and against any and all claims, damages, liabilities, and costs (including attorney s fees) arising as a result of the Custodian s payment of my HSA in accordance with the foregoing Beneficiary Designation or the Beneficiary Designation in effect on the date of my death. Spousal Consent to Beneficiary Designation (if applicable) NOTE: This section should be signed by the spouse of the Account Holder named on page 1 above if your state requires the consent of your spouse to the designation of a beneficiary other than your spouse with respect to the HSA. This could apply, for example, if you live in a community or marital property state and you designate someone other than or in addition to your spouse as beneficiary. Consult your attorney or tax advisor for further information. The undersigned spouse of the Account Holder named on page 1 hereby consents to and joins in the designation of beneficiary (ies) identified above. To the extent that the undersigned spouse is not named as Beneficiary, such spouse relinquishes any interest he or she has in the funds contained in this Health Savings Account. Printed Name of Spouse: Signature of Spouse: Future HSA Contributions Following any initial contribution, I understand that in general, additional deposits to my HSA account at Community Trust and Investments must be made by payroll deduction. If I want to make additional contributions (other than via payroll deduction), I must contact BDG Benefits Design Group, Inc

3 Investment Option Election Funds deposited to Health Savings Accounts are held by Community Trust and Investment Company and invested by Merrill Lynch. Assets are to be invested to provide for the short, intermediate and long-term healthcare needs of individuals in the plan. 1. The asset classes to be used for these purposes are cash equivalents, stocks (common & select preferred stocks), and bonds. 2. The investment manager retains authority to modify the re-balancing of individual models, as listed in the investment guidelines that are attached. Account balances of $200 or less receive no investment return. Account balances of $200 or more receive an investment return as determined and allocated monthly by the Trustee based on investment results from a pooled account managed by the investment manager in highly liquid, short term money market investments. Upon reaching an individual account balance of $5,000, an individual may elect participation by going direct through Merrill Lynch. Investment Policy Guidelines The Health Savings Account funds will be invested in pooled accounts for the participants with two primary objectives: 1. Liquidity having high assurance that liquid funds will be available for use by participants for healthcare expenses on a timely basis. 2. Safety of Principal maintaining a high degree of confidence (though no guarantee) that risk of loss of principal will be minimal. The funds will be invested and managed by Merrill Lynch in various financial instruments and investment vehicles, consistent with and suitable for the above objectives. It is expected that these investments will include: 1. Cash and Cash Equivalent Investments in highly liquid, high quality, fixed income short term money market instruments, including US Government and Treasury obligations, US Government guaranteed Agency obligations, bank certificates of deposit, highest quality rated commercial paper, and repurchase agreements. 2. Fixed Income US Government bonds or US Government guaranteed bonds with intermediate and longer term maturities. 3. High quality rated corporate corporate bonds, issued by US and Foreign corporations with intermediate and longer term maturities. 4. Selective common and preferred equities (stock) as appropriate, although it is expected that equities will comprise a small component of the overall investment pool particularly in the early stages of the program. 5. Mutual funds comprised of various fixed income and equity securities selected from an approved list of appropriate low risk funds by Merrill Lynch, the asset manager. The investment return will be allocated and distributed to the individuals accounts based on their pro rata share of the pooled fund. The investment policy for this program will be reviewed from time to time and may be subject to revision by the Program and Investment Managers. 3

4 Health Savings Account Fee Schedule Administrative and Custodial Fees Community Trust & Investment Company, as custodian of Health Savings Accounts, charges Account Owners the following fees for providing custodial and administrative services for Health Savings Accounts. These fees are subject to change from time to time, as provided in Section 6.01 of the Community Trust Health Savings Account Custodial Agreement. Initial Setup Fee Waived Monthly Custodial Fee $2.15 per month for each Health Savings Account Distribution Fees (To close the account) For Health Savings Account distributions made by debit card no additional charge. For distributions processed by check a $25 fee applies. Monthly Fee (After termination) Monthly cost for Health Savings Account after termination from employer health plan - $4.00 per month. 4

5 COMMUNITY TRUST HEALTH SAVINGS ACCOUNT ADOPTION AGREEMENT By submitting the completed Enrollment Form and Agreements, I am offering to adopt the Community Trust Health Savings Account Custodial Agreement and to establish a Heath Savings Account with Community Trust & Investment Company, as custodian. Representations By submitting the Enrollment Form and Agreements, I represent that: All of the stated information on the Enrollment Form and Agreements is correct; I am covered under a high deductible health plan within the meaning of section 223(c)(2) of the Internal Revenue Code; I am not covered by any other health plan that is not a high deductible health plan, except for coverage disregarded in section 223(c)(1)(B) of the Code (including coverage for worker s compensation liability, tort or property liability, a specified disease or illness, paying a fixed amount per period of hospitalization, accidents, disability, dental care, vision care, or long-term care); I am not enrolled in Medicare; and I cannot be claimed as a dependent on another person s Income tax return. Adoption By submitting the Enrollment Form and Agreements, I adopt the Community Trust Health Savings Account Custodial Agreement, establish a Health Savings Account pursuant to its terms, and agree to be bound by its terms. Date: (Signature of Applicant] Acceptance of Adoption Agreement Community Trust & investment Company accepts the applicant s offer to adopt the Community Trust Health Savings Account Custodial Trust Agreement and to establish a Health Savings Account. Date: Community Trust & Investment Company by Authorized Signature 5

6 COMMUNITY TRUST HEALTH SAVINGS ACCOUNT CUSTODIAL AGREEMENT ARTICLE I Purpose This Health Savings Account Custodial Agreement, when adopted by an individual Account Owner, establishes the terms under which Community Trust & Investment Company will serve as custodian of a Health Savings Account established for the benefit of the Account Owner. The effective date of this Agreement is, Defined terms used in this Agreement are capitalized and have the meanings explained in Article X. ARTICLE II Establishment of Accounts Section Eligible Individual's Account. An Eligible Individual establishes an Account upon delivery of a completed Adoption Agreement to the Custodian and the Custodian's acceptance by executing the Adoption Agreement. Section Exclusive Benefit. All Accounts are established exclusively for the purpose of paying or reimbursing Medical Expenses of an Account Owner and his or her Dependents and Beneficiaries. Section Accounts Nonforfeitable. The Account Owner's interest in the balance in his or her Account is nonforfeitable at all times. ARTICLE III Contributions Section Regular Contribution Restrictions. Except for Rollover Contributions, contributions may be made by or on behalf of an Account Owner for a month only if the Account Owner is an Eligible Individual for that month. Those contributions may not exceed one-twelfth of the sum of (a) the applicable Contribution Limit and (b) any Catch-Up Contributions allowable for that Account Owner. The Custodian may establish from time to time a minimum contribution amount. Section Timing and Form of Regular Contributions. Contributions by or on behalf of the Account Owner must be made to the Custodian in cash. Contributions for a particular tax year may be made at any time before the deadline for filing the Account Owner's federal income tax return for that year, without extensions. Section Rollover Contributions. Upon submitting such information as the Custodian requests, an Account Owner may make Rollover Contributions in cash at any time and in any amount. Section Limitation on Custodian's Obligation. Except for Rollover Contributions, the Custodian will accept contributions by or on behalf of an Account Owner for a tax year to the extent that they do not exceed the sum of (a) the Contribution Limit for an Account Owner with Family Coverage and (b) the Catch-Up Contributions allowed for that tax year. With that exception, the Custodian has no obligation to reject any contribution that exceeds any limits established by this Agreement or the Code and may rely solely on an Account Owner's representations in the Adoption Agreement or other submissions to the Custodian. If the Account Owner notifies the Custodian that contributions have exceeded the limits, the Custodian will process corrective withdrawals as provided in Section ARTICLE IV Account Assets Section Investment Direction. The Account Owner may direct the Custodian to invest the assets of the Account in any of the investment vehicles that the Custodian makes available for holding Health Savings Account assets, as listed on the Fee and Investment Schedule. Section Commingling of Assets. The Custodian may not commingle the assets of an Account with other property except in a common trust fund or common investment fund. Section Prohibited Holdings. The Custodian may not invest any assets of an Account in life insurance contracts or in collectibles as defined in Code section 408(m). Section Prohibited Transactions. Neither the Account Owner nor the Custodian will borrow against the Account, pledge the Account as security for borrowing, or engage in any other prohibited transaction as defined in Code section ARTICLE V Distributions Section Directed Distributions. An Account Owner may direct the Custodian to distribute all or any part of the Account, subject to any minimum distribution limit that the Custodian may establish from time to time, by presenting a debit card, by drawing a check against the Account, or by any other means made available by the Custodian. Section Tax Status of Lifetime Distributions. Distributions used exclusively to pay or reimburse Medical Expenses are tax-free. Distributions for other purposes, however, are included in the Account Owner's gross income and are subject to an additional 10 percent on that amount, unless made after the Account Owner's death, disability, or reaching age 65. Section Substantiation of Medical Expenses. The Account Owner is solely responsible for substantiating that a distribution is for the payment or reimbursement of Medical Expenses and for maintaining records sufficient to show, if required, that the distribution is tax-free. 6

7 Section Excess Contributions Withdrawal. If the Account Owner notifies the Custodian that any contributions have exceeded the applicable Contribution Limit, the Account Owner may request withdrawal of the excess contributions and any net income attributable to those excess contributions. The Custodian will return those amounts no later than the Account Owner's tax return due date for that tax year. Section Designation of Beneficiary. An Account Owner may designate a Beneficiary who is to receive the Account or change a designated Beneficiary. To be effective, the designation or change must be in writing and must be received by the Custodian prior to the Account Owner's death. Absent a designation by the Account Owner, the Account assets will be paid to any beneficiary designated on the Adoption Agreement for the High Deductible Health Plan or, in the absence of any such designation, to the Account Owner's estate. Section Account Owner's Death. In the event that the Account Owner dies before the Account assets are distributed, the balance of the Account will be disposed of as follows: (a) If the Beneficiary is the Account Owner's spouse at the date of death, the Account will become the spouse's Health Savings Account as of the date of death. The spouse must submit a revised Adoption Agreement within 90 days following the Account Owner's death. (b) If the Beneficiary is not the Account Owner's spouse at the date of death, the Account will cease to be a Health Savings Account as of the date of death, and the Custodian will distribute the full value of the Account to the Beneficiary as soon as practicable following notification of the Account Owner's death. (c) If the Beneficiary is the Account Owner's estate, the fair market value of the Account as of the date of death is taxable on the Account Owner's final return. For any other non-spouse Beneficiary, the fair market value of the Account is taxable to the Beneficiary in the tax year that includes the date of death. Section Lifetime Transfers of Accounts. During the Account Owner's lifetime, transfers of the Account will be subject to the following: (a) Account assets may be transferred to the Account Owner's spouse or former spouse under a divorce or separation instrument described in Code section 71(b)(2)(A). In that event, the spouse or former spouse will become the Account Owner of an Account consisting of the transferred assets. (b) Except for a transfer incident to divorce under the preceding subsection, an Account will not be subject to alienation, assignment, pledge, garnishment, attachment, execution, or levy of any kind, and any attempt to do so will not be recognized except to such extent as may be required by law. ARTICLE VI Fees, Allocations, and Reporting Section Fees. The Custodian will establish and collect fees from each Account as provided from time to time in the Fee and Investment Schedule. The Custodian may change the Fee and Investment Schedule by notifying the Account Owner of the changes at least 30 days in advance of the effective date of the changes. Section Allocations. Each contribution will be allocated to the Account as of the date the contribution is received by the Custodian or by an investment provider that it designates. Earnings will be allocated to the Account at the end of each calendar month. Section Reporting. At least once per calendar year, the Custodian will provide each Account Owner a statement of the Account during that period. ARTICLE VII Powers and Duties of Custodian Subject to any applicable provision of the Code, the Custodian will have the powers and duties described in this Article. Section Powers. The Custodian may exercise any and all powers the Account Owner or his or her spouse or Beneficiary could exercise as owner of property held in the Account, including the following powers: (a) this Agreement; to receive and hold contributions under (b) to hold any Account assets in the Custodian's name; and (c) to hold Account assets in cash or other forms in accordance with this Agreement. Section Duties. The Custodian will have the following duties: (a) to follow the Account Owner's directions with respect to accepting contributions, investing Account assets, making distributions, and withdrawing excess contributions; (b) to keep accurate and detailed accounts of all contributions, distributions, earnings, and other transactions made for an Account; and (c) to prepare and submit any reports and returns required by the Code. 7

8 Section Limitation on Duties. The Custodian will have only the duties specifically set forth in this Agreement. The Custodian will use ordinary care and reasonable diligence in performing its duties. The Custodian will not be liable for any loss that is not a result of its negligence or willful misconduct. In performing its duties under this Agreement, the Custodian may hire agents, experts, and attorneys and delegate discretionary powers to, and rely upon, information and advice furnished by such agents, experts, and attorneys. An Account Owner will have the sole authority and responsibility for the enforcement or defense of the terms and conditions of the Agreement against or on behalf of any person or persons asserting any claim to an Account. The Custodian will not be required to prosecute, defend, or respond to any action or any judicial proceeding relating to the Account unless it has previously received indemnification satisfactory to it in form and substance. The Custodian will be under no duty to question any direction of the Account Owner with respect to the distribution of any Account assets. The Custodian will not be required to give bond or security for the performance of its duties. Section Indemnification. An Account Owner will indemnify and save harmless the Custodian from any liability, cost, or expense which may arise in connection with this Agreement, except any liability, cost, or expenses arising from the negligence or willful misconduct of the Custodian. The Custodian may rely on the representations of an Account Owner or Beneficiary on matters relating to this Agreement and will be under no duty to make further investigation. ARTICLE VIII Amendments and Termination Section Amendments. The Custodian will amend this Agreement from time to time to comply with the provisions of the Code. For other purposes, the Custodian may amend this Agreement prospectively upon written notice to an Account Owner 30 days in advance of the effective date of the amendment. Section Termination. An Account Owner or the Custodian may terminate an Account at any time by written notice to the other party. Upon such termination, the Custodian will distribute all assets in the Account, less any of the Custodian's fees and less any required tax withholding, to the Account Owner in one lump sum as soon as practicable after notice of termination is given. Upon the completion of such distribution, the Custodian will be relieved from all further liability with respect to all amounts so paid. Section Resignation of Custodian. The Custodian may resign at any time upon 30 days' prior written notice to the Account Owner. Not later than the effective date of the resignation, the Account Owner may direct a complete distribution of his or her Account, less any amounts necessary for the payment of the Custodian's fees and expenses. If the Account Owner does not direct a complete distribution by the effective date of the resignation, the Custodian may make a distribution of the Account as soon as practicable or may designate a successor custodian and give notice in writing of its designation to the Account Owner. The successor custodian so designated and accepting a custodianship under this Agreement will have all the rights, powers, duties, and obligations of the original Custodian. ARTICLE IX Miscellaneous Section Rights Limited. Neither the establishment of the Account nor any Account transaction will be construed as giving the Account Owner or any other person any legal or equitable right against the Custodian except as provided in this Agreement. Section Sole Source of Distributions. An Account Owner will look solely to the assets of his Account for the payment of any distribution to which the Account Owner is entitled under this Agreement. Section Changes in Account Owner Information. An Account Owner will notify the Custodian in writing of any change in marital status, name or address of any Dependent, or the obtaining of any health plan other than a High Deductible Health Plan, or other representations or information previously provided to the Custodian. An Account Owner will also provide the Custodian all information that the Custodian reasonably believes necessary for the Custodian to prepare any report or return required by the Code or to perform any of its other obligations under this Agreement or the Code. ARTICLE X Definitions and Rules of Construction Section Terms Defined. As used in this Agreement, the following terms have the following meanings: (a) "Account" means a Health Savings Account as described in Code section 223(d). (b) "Account Owner" means an Eligible Individual who has established an Account under Section (c) "Adoption Agreement" means the Community Trust Health Savings Account Adoption Agreement by which an individual adopts this Agreement and establishes an Account under the terms of this Agreement. (d) "Agreement" means this Community Trust Health Savings Account Custodial Agreement, as amended from time to time. (e) "Beneficiary" means a person designated by an Account Owner under Section 5.04 to receive the Account Owner's remaining Account after his or her death. (f) "Catch-Up Contributions" means additional contributions for a tax year on behalf of Account Owners who have attained age 55 before or during that tax year, as provided under Code section 223(b)(3). The maximum amount of Catch-Up Contributions is $500 for 2004, increasing in annual increments of $100 until the amount reaches $1,000 for (g) "Code" means the Internal Revenue Code of 1986, as amended from time to time, and its interpretive rules and regulations. 8

9 (h) "Contribution Limit" means, with respect to an Account Owner for a tax year, the High Deductible Health Plan's deductible amount, but not more than $3,000 per year for an Account Owner with Single Coverage or $5,950 per year for an Account Owner with Family Coverage (Plan Year 2009). (i) "Custodian means Community Trust & Investment Company, acting its capacity as custodian of each Account for the benefit of its Account Owner. (j) "Dependent means the Account Owner's spouse or the Account Owner's dependent within the meaning of Code section 152. (k) "Eligible Individual" means, with respect to a month, an individual who, as of the first day of the month, is covered by a High Deductible Health Plan and satisfies all other requirements of Code section 223(c)(1). (l) "Family Coverage" means any Account Owner coverage under a High Deductible Health Plan that is not Single Coverage. (m) "Fee and Investment Schedule" means the current schedule custodial fees and investment options attached to, and incorporated in, this Agreement. (n) "High Deductible Health Plan" means a health insurance plan that satisfies the minimum deductible and other requirements established by Code section 223. (o) "Medical Expenses" mean amounts paid on behalf of the Account Owner or his or her Dependents (i) for medical care as defined in Code section 213(d) if not compensated for by insurance or otherwise or (ii) for certain health insurance specifically allowed under Code section 223(d)(2). (p) "Rollover Contribution" means a rollover contribution from another Health Savings Account or Archer Medical Savings Account as described in Code section 223. (q) "Single Coverage" means Account Owner coverage under a High Deductible Health Plan that is for the Account Owner only. Section Rules of Construction. The following rules of construction will govern in interpreting this Agreement: (a) In the event of any conflict between provisions of this Agreement and Code section 223, the conflicting provisions of this Agreement will be void. (b) If any provisions of this Agreement are held to violate the Code or be illegal or invalid for any other reason, that provision will be void, but the invalidation of that provision will not otherwise impair or affect the Agreement. (c) Other than as specified in subsection (a) or (b), the provisions of this Agreement will be governed by the internal laws of the State of Indiana. 9