Enrollment Kit Welcome Letter

DearEmployees:

Weareexcitedtotellyouaboutagreatbenefityourcompanyisofferingtoitsemployees.It’s calledaSection125CafeteriaPlanorFlexibleBenefitsPlan.ByusingtheFlexibleSpending Account(FSA)availablethroughtheplan,youcan saveagreatdealofmoney. The savingsisachievedbynotpayingtaxesontheamountyouputintoyouraccountforhealth careanddependentcareexpenses.

YourFlexibleBenefitsPlanincludesthreecomponents:

HealthCareSpendingAccount–pre-taxdollarssetasidetocoverout-of-pocketmedical expensesnotcoveredbyyourplan.

DependentCareSpendingAccount–pre-taxdollarsthatcanbeusedtopayfordaycarefortax dependents.

PremiumConversion–allowsyoutohaveyourbenefitpremiumsdeductedpretaxfrompayroll.

Here’showitworks.Eachpayroll,yourcompanyplacestheamountyoudesignatefromyour payintoyourpersonalhealthand/ordependentcarespendingaccounts.Themoney– whichisputasidewithoutbeingtaxed–isearmarkedforout-of-pocketexpenses.Those expensesmightincludeyourdaycarebill,aco-payforavisittothedoctororaprescription.

ThemoneyyoucansavebyusingyourFSAcanbesignificant. Forexample,EmployeeAearns$1,700permonth.Sheelectstoplace$60inherHealthFSA,$260inherDependent Care FSAandalsohasher$50healthplancontributiontakenoutbeforetaxeachmonth.By takingcareofthesenecessaryexpensesonapre-taxbasis,shecouldsaveover$100intaxes permonth,moneyshewillsurelybehappytospendelsewhere.

Everyemployee’ssituationisalittledifferent,butthereisareasonthisplaniscalledaFlexibleBenefitsPlan.Itcanbeusedtosuityourneedsandwillsaveyoumoney.

Participationiseasy.Justreviewtheenrollmentmaterialsprovidedforalltherules,calculate yourexpensestodetermineyourannualelection,fillouttheenrollmentformandstartsaving.

Ifyouhavequestionsaboutyourplan,pleasecontactyourHRrepresentative.

15 E. Washington St. • PO Box 488 • Coldwater, MI 49036-0488 • 866-370-3040 • Fax: 800-379-5670 • E-mail:

FSA worksheet

Estimated unreimbursed health care expenses

Medical / Annual amount / Dependent Day Care / Annual amount
Deductible / 2 / (necessary for you and your spouse to work)
Coinsurance payment / 3 / After-school care
Contraceptives / 4 / Care of other dependents
Doctor’s office visits / 5 / Child care/day care center
Immunizations / 6 / Child care in home
Insulin / 7 / Preschool
Laboratory tests / 8
Other expenses / 9 / TOTAL2
Over-the-counter medicine1 / 10
Physicals/annual checkups / 11
Prescription drugs / 12
Splints, supports, corrective devices / 13
Therapy treatments (medical reasons only) / 14
Well-baby care / 15
SUBTOTAL / 16
Dental / 17
Deductible / 18
Coinsurance payment / 19
Cleaning / 20
Dentures / 21
Fillings/crowns/bridges / 22
Fluoride treatments / 23
Orthodontia
(based on expenses incurred for upcoming plan year) / 24
X-rays / 25
SUBTOTAL / 26
Vision / 27
Deductible / 28
Coinsurance payment / 29
Contact lenses and solutions / 30
Examinations / 31
Frames / 32
Laser eye surgery / 33
Lenses / 34
SUBTOTAL / 35
TOTAL / 36

Unreimbursed health care expenses cannot exceed your plan’s maximum.

NOTE: any coordination of benefits with another group plan may reduce your out-of-pocket expenses.

1Effective January 1, 2011, over-the-counter medicines or drugs are not eligible for reimbursement under Health Flexible Spending Accounts (FSA) or health Reimbursement Arrangements (HRA) without a doctor’s prescription.

2Cannot exceed $5,000 ($2,500 if married, filing separately), per calendar year or earned income of employee or spouse, whichever is less.

KnowyourFSA/HRAEligibleand IneligibleExpenses

Maximize the Valueof YourReimbursementAccount

YourHealthFlexibleSpendingAccount(FSA)and/orHealthReimbursementAccount(HRA)dollarscanbeusedfor avarietyof out-of-pockethealthcareexpenses.Thefollowinglist is basedoneligibleand ineligibleexpensesusedby federalemployees.

EligibleExpenses
BABY/CHILD TOAGE 13

Lactationconsultant*
Lead-basedpaintremoval
Specialformula*
Tuition:specialschool/teacher fordisabilityor learningdisability*
Wellbaby/wellchild care

DENTAL

Dentalx-rays
Denturesand bridges
Examsandteethcleaning
Extractionsandfillings
Oral surgery
Orthodontia
Periodontal services

EYES

Eye exams
Eyeglassesandcontactlenses
Lasereyesurgeries
Prescriptionsunglasses
Radialkeratotomy

HEARING

HearingAidsandBatteries
HearingExams

LAB EXAMS/TESTS

Bloodtestsandmetabolismtests
Bodyccans
Cardiograms
Laboratoryfees
X-Rays

/ MEDICALEQUIPMENT/SUPPLIES

Air purification equipment*
Arches and orthoticinserts
Contraceptivedevices
Crutches,walkers,wheelchairs
Exerciseequipment*
Hospitalbeds*
Mattresses*
Medicalertbraceletor necklace
Nebulizers
Orthopedicshoes*
Oxygen*
Post-mastectomy clothing
Prosthetics
Syringes
Wigs*

MEDICALPROCEDURES/SERVICES

Acupuncture
Alcoholanddrug/substance abuse (inpatienttreatmentandoutpatient care)
Ambulance
Fertilityenhancementandtreatment
Hair losstreatment*
Hospitalservices
Immunization
InVitrofertilization

Physical examination (notemployment-related)

Reconstructivesurgery(duetoa congenitaldefect,accident, ormedical treatment)
Serviceanimals
Sterilization/sterilizationreversal
Transplants(includingorgandonor)
Transportation*

/ MEDICATIONS

Insulin
Prescription drugs

OBSTETRICS

Doulas*
Lamazeclass
OB/GYN exams
OB/GYN prepaidmaternityfees

(reimbursableafter date ofbirth)

Pre- andpostnataltreatments

PRACTITIONERS

Allergist
Chiropractor
ChristianSciencePractitioner
Dermatologist
Homeopath
Naturopath*
Optometrist
Osteopath
Physician
Psychiatrist or Psychologist

THERAPY

Alcoholanddrugaddiction
Counseling(notmarital orcareer)
Exerciseprograms*
Hypnosis
Massage*
Occupational
Physical
Smokingcessationprograms*
Speech
Weightlossprograms*

HRAELIGIBLE

Insurance premiums
Long-termcare premiums

Note:Thislistisnotmeanttobe all-inclusive,asotherexpensesnotspecificallymentioned mayalsoqualify.Also,expensesmarked with an asterisk(*)are“potentiallyeligibleexpenses”thatrequireanote ofmedicalnecessityfromyour healthcare provider toqualify for reimbursement.Foradditionalinformation,check your SummaryPlanDocumentor contactInfinisource.

15 E. Washington St. • PO Box 488 • Coldwater, MI 49036-0488 • 866-370-3040 • Fax: 800-379-5670 • E-mail:

TheIRSdoesnotallowthefollowingexpensestobereimbursedunderHealthFSAsorHRAs,as theyare notprescribedbyaphysicianforaspecificailment.

IneligibleExpenses

Contact lensor eyeglassinsurance
Cosmeticsurgery/procedures
Electrolysis

Insurance premiumsand interest

(FSA ineligibleonly)

Long-termcarepremiums

(FSAineligible only)

Marriage or careercounseling

Personaltrainers
Sunscreen(SPF lessthan30)
Swimminglessons

Note:Thislistisnotmeanttobe all-inclusive.

Pleasenote: TheIRSwillnot allowOTCmedicinesordrugstobepurchasedwithHealthFSAorHRAfunds unlessaccompaniedbya prescription.

EligibleOver-the-CounterItems
Note:Productcategoriesarelistedinboldface;commonexamplesof productsarelistedinregular face.
Thefollowingisahighlevellist ofover-the-counter (OTC) itemsthat clearlyarenot medicineor drugs andare eligiblefor purchasewithHealthFSAor HRAdollars. You canuseyour benefits cardfor theseitems

Antiseptics,wound cleansers

Alcohol,peroxide,Epsomsalt

Babyelectrolytes

Pedialyte, Enfalyte

Denture adhesives,repair and cleansers

PoliGrip, Benzodent,Efferdent

Diabetestesting andaids

Insulin, Ascencia, OneTouch, Diabetic Tussin,insulinsyringes,glucoseproducts /

Diagnosticproducts Thermometers,bloodpressure monitors, cholesteroltesting
Elastics/athletictreatments ACE, Futuro,elastic bandages, braces, hot/coldtherapy, orthopedic supports,ribbelts
Eye care

Contact lenscare

Familyplanning

Pregnancy andovulationkits /

First aiddressingsandsupplies

Band Aid,3M Nexcare,non-sport tapes

Hearing aid/medicalbatteries
Incontinenceproducts Attends, Depend,GoodNites for juvenileincontinence
Readingglassesandmaintenance accessories

Foradditionalinformation,pleasecontact:

Infinisource,Inc.Phone: 866.370.3040

POBox488Fax: 800.379.5670

Coldwater,MI49036-0488Email:

15 E. Washington St. • PO Box 488 • Coldwater, MI 49036-0488 • 866-370-3040 • Fax: 800-379-5670 • E-mail:

SavingsSnapshot

You can increase the money you take home each pay period by using a Flexible Benefits Plan. Here is an example of the tax savings anemployee earning $2,200 a month can experience using this great benefit.

Monthly income before taxes / Without 125 Plan
$2,200.00 / With 125 Plan
$2,200.00
Pre-tax salarydeductions
Health FSA contribution / $.00 / $60.00
DependentCare FSA contribution / $.00 / $260.00
Employee contribution to health plan / $.00 / $50.00
Total / $.00 / $370.00

Payrolltaxes

FICA (7.65%) / $168.30 / $140.00
Federal income tax (12.16%) / $267.52 / $222.53
State income tax (4%) / $88.00 / $73.20
Total / $523.82 / $435.73

After tax expenses

Health care expenses / $60.00 / $.00
Dependentcare expenses / $260.00 / $.00
Employee contribution to health plan / $50.00 / $.00
Total / $370.00 / $.00
Spendable income / $1,306.18 / $1,394.27

Employee’sspendableincomeincreases

$22.03 each week

$88.09 each month

$1,057.08each year

FrequentlyAskedQuestions

GeneralInformation

WhyshouldIparticipateintheFlexibleBenefitsPlan?

There are some great advantages to using a Flexible Benefits Plan!

Reduced taxes - themoneycontributedtoanFSAisnotsubjecttotaxes(federal incomeandFICAtaxesandmoststateandlocalincometaxes).
Increase your take-home pay – less taxes, more money in your pocket
The Benny Card – pay for expenses at point of purchase

AFlexibleBenefitsPlan appliestoout-of-pocketexpensesyoucoverwithyourspendableincome,butallowsyouto payfortheseexpenseswithincomebeforeyouaretaxed.

Another advantage to participating in the Plan is the opportunity it offers for you to budget for health care expenses by withholding a small amount from each paycheck. With proper planning, you won’t be faced with having to come up with large amounts of money at one time. This is especially advantageous if you are scheduling a surgery, anticipating maternity expenses or if you do not have other coverage for dental and vision expenses. Even those with coverage for medical, dental and vision usually have deductibles, co-pays and other out-of-pocket expenses to cover.

WheredoIcallwithquestionsaboutmyFlexibleBenefitsPlan?

Ifyouhaveanyquestionsabout puttingaFlexibleBenefitsPlantoworkforyou,howtosign uporhowtodetermineyourelectionamounts,etc.,pleasecallaCustomerService Representativeat866-370-3040.

Enrollment

HowdoI enroll?

ToenrollineitherorboththeHealthandDependentCareFSA,yousimplyneedtofilloutthe EnrollmentForm/DirectDepositFormbeforethebeginningofeachPlanYear.

DoIhavetokeepthesameelectioneachyear?

No.Eachyear,youwillhaveto re-enrollbeforethebeginningof thePlanYear.Atthat time,you willhave theopportunitytoevaluatethe needtoparticipateinthe Planaswellasbudgetforall healthcareand/ordependentcareexpenses. Youmaydecidetokeepthesameelection, changeyourelectionorinsomecaseswaiveparticipation.

DoIhavetoelectboththeHealthandDependentCareFSAs?

No.Youmaychoosetoparticipateinoneorbothdependingonyourindividualneeds.

HealthFSAs

WhatisaHealthFlexibleSpendingAccount(FSA)?

Youmaysetasidepre-taxdollarstocovereligiblemedicalexpensesthatarenotcoveredby anyothertypeofinsurance.Theaccounthelpsyoubudgetforplannedexpensessuchas deductibles,co-paymentsandprescriptions.Youmayreferto theFSAWorksheetforalistof someeligibleandineligibleexpenses.

Areinsurancepremiumsaneligibleexpense?

No,insurancepremiumsarenotreimbursablefromaHealthFSA.However,youmaypayyour requiredpremiumcontributions(forcoverageundertheemployer’shealthplan)onapre-tax basisoutsideoftheHealthFSA.

What are some examples of OTC drugs that are eligible for reimbursement from my Health FSA?

Antiseptics, diabetes testing aids, bandages and contact lens care. Foramoreinclusivelist,pleaseseetheOTCexpenseslistavailableat

IfIterminateemploymentorretire,canIreceivetheremainingbalanceinmyHealthFSA?

No.However,youcancontinuetosubmitclaimsincurredpriortoyourterminationdatebefore theendoftherun-outperiod(definedinyourSummaryPlanDescription).

Example: Yourplanhasa90-dayrun-outperiodfollowingtermination.Yourtermination dateisSeptember13.YourphysicianseesyouonSeptember12,butyoudonotreceivethe ExplanationofBenefitsfromyourinsurancecarrieruntilOctober31.Youcanstillsubmitthis expenseasitwasincurredpriortoyourterminationdate,andpriortotheendofthe90-day run-outperiodfollowingyourdateoftermination.AnyexpenseincurredafterSeptember13is noteligible.

IfIterminateemploymentorretirecanIbereimbursedforexpensesincurredaftermy terminationdate?

No.Inordertobeconsideredaneligibleexpense,theexpensemustbeincurredpriortoyour terminationdate.However,youmaybeabletocontinueyourHealthFSAcoverageunder COBRA.

DependentCareFSAs

WhatisaDependentCareFSA?

You can use pre-tax dollars to cover eligible work-related dependent care expenses for qualified dependents, or if you are married, while you and your spouse work or your spouse attends school full-time.

Whoisa qualifieddependentundertheDependentCareFSA?

Dependentundertheageof13
Dependentorspouseofemployeewhoismentallyorphysicallydisabledandwhomthe employeeclaimsasa dependentonhisorherfederalincometaxreturn

Cananadultbeaqualifieddependent?

Yes,anadultmayqualifyasadependentprovidedthattheemployeeisprovidingmorethan halfofthatindividual’ssupportfortheyearandthedependentliveswiththeemployee.

DoIhavetouseadaycarefacility?

No.Youcanbereimbursedforexpenses of anindividualprovidingcareforyour dependentinyourhomeaslongastheexpensesareincurredforyouandyourspouse(if married),towork,lookforworkorattendschoolfull-time.

Doesmydaycareproviderhavetobelicensed?

No.However,youarerequiredtosubmit theirTaxIdentificationNumberorSocialSecurity Numberwhenfilingyourfederalincometaxreturn.

Doesmydaycareproviderhavetobe18?

No,buttheindividualmustclaimthemoneyasincomeontheirtaxreturn.

Mychildattendscampduringthesummer.Isthiseligible?

Generally, no; however, if the camp is day camp and your dependent attends to allow you and your spouse (if married), to work, look for work or attend school full-time, then yes this would be an eligible expense. Overnight camps are specifically excluded.

WhencanIbereimbursedfordependentcareexpenses?

Expensesareeligibleforreimbursementwhentheyhavebeenincurred,notwhenyouarebilled orwhenyoupayfortheservices.

Example: Your day care provider requires you to pay for the month of September on September 1. You can be reimbursed as the services are incurred, not when you paid for the services. You can submit claims after each week, every two weeks or on October 1.

ChangingYourElection

WhatifIdiscoverthatIelectedtoomuchfortheHealthand/orDependentCareFSA,canI changemyelection?

Generally,yourelectionisirrevocableunlessyouexperienceanIRSChangeinStatus. Yourelectionchange must be consistentwiththeChangeinStatusevent:

Changeinlegalmaritalstatus(marriage,deathofspouse,divorce,legalseparation, annulment)
Changeinnumberoftaxdependents(birth,deathofdependent,adoptionorplacementfor adoption)
Changeindependent’seligibility
Changeinemploymentstatusofemployee,spouseordependents
Otherchangesthatmaypermitan electionchangeundertheDependentCareFSAare:

Changeofdependentcareprovider
Changeofratechargedbyunrelateddependentcareprovider
Childattainingage13

Electionchangesmustbeconsistentwiththeevent.IfyouexperienceaChangeinStatus, pleasereviewyourSummaryPlanDescription,asitwillprovideyouwithimportantinformation onthedeadlineforreportingthisevent.

IfIelectedtoomuchinmyHealthFSAbutnotenoughinmyDependentCareFSA,canI movemoneyfromoneaccounttotheother?

No, Health and Dependent Care FSA elections are separate. You cannot move contributions from one account to another. Also, it is very important to note that the elections you make are for the entire year. Your elections cannot be changed unless you experience an IRS Change in Status as noted above.

WhathappensifIdon’tuseallthemoneyelectedinmyFSA?

TheIRShas issued guidance that allows a Health FSA to carry over up to $500 to the next plan yearby plan design based on the plan sponsor’s decision. A Health FSA cannot have both a carryover and a grace period of up to two months and 15 days. You also havea run-outperiodfollowingtheendoftheplanyeartosubmitexpensesthatwereincurredduring theplanyear.Itisimportanttoestimateyourexpensescarefullybeforemakingyourelections.

Infinisource willassistyouinmonitoringyourFlexibleSpendingAccountsbyprovidingyou withastatementatthebeginningofthefourthquarterofyourplanyear.Youcanminimize possible forfeituresbyschedulingroutineexams,purchasingglassesorcontactlensesandscheduling dentalappointments,etc.,attheendoftheplanyeartouseupyourelectionamounts.

SubmittingClaimsforReimbursement

HowdoI submitaclaimfortheHealthorDependentCareFSA?

You can file your claim online or via mobile app and upload your receipts. You can completeanFSARequestforReimbursementFormforeachHealthorDependent CareFSAclaimyoufile.Remembertoattachsupportingdocumentationfortheclaim.This informationcanbefaxedto800-379-5670.

Youmayalsosubmityourclaimbymail: Infinisource,Inc.

POBox488, Coldwater,MI49036-0488

MayIsubmitexpensesformyspouseandchildrenforreimbursementthroughmyHealth FSA?

Yes,youmaybereimbursedforexpensesincurredforyou,yourspouseandanyIRS dependents,regardlessofwhereyouareinsured.Itcouldbethatyouarenotcoveredthrough youremployer’shealthplan,buthavecoveragethroughyourspouse’semployer’splan.You maystillsubmityourfamilyout-of-pocketexpensestobereimbursedundertheHealthFSA.

WhatsupportingdocumentationmustIfilewitheachHealthFSAclaim?

Eachtimeyousubmitclaimstoyourhealthinsurancecarrier, youwillreceive an ExplanationofBenefits (EOB) detailingwhatthehealthplanwillpayandwhatyoumustpay. Forexpensesthatarepartiallycoveredunderanotherinsuranceplan,youmustattachacopy ofbothEOBs.

Forexpensesthatarenotsubmittedtoanotherinsuranceplan,youmust attachacopyofanitemizedbillingcontainingthefollowinginformation:

Nameofpatient
Nameandaddressofprovider
Descriptionofservice
Dateofservice
Amountofservice

ThedocumentationrequirementsarealsolistedontheFSARequestforReimbursementForm toassistyouinproperlyfilingyourclaim.Followingtheseguidelineswillensureyoureceive yourreimbursementwithoutunnecessarydelays.

WhatsupportingdocumentationmustIfilewitheachDependentCareclaim?

CompletetheDependentCaresection of the RequestforReimbursementForm andhaveyour daycareprovidersignanddate. Thereceiptmustincludethefollowing information:

Nameandaddressofprovider
From/throughdatesofservice
Amountofcharge

HowlongaftertheendofthePlanyeardoIhavetosubmitclaims?

Claimsmustbesubmittedpriortotheendoftherun-outperiodforthePlan.Therun-outperiod isdefinedinyourSummaryPlanDescription.

WillIreceivereimbursementforclaimsthataregreaterthanthecurrentbalanceofmy HealthFSA?

Yes,theannualamountisavailabletoyoufromthebeginningofthePlanyear.

WillIreceivereimbursementthatisgreaterthanthecurrentbalanceofmyDependent CareFSA?

No,youwillonlyreceivereimbursementfortheamountthathasbeencontributedatthetimeyou submityourclaim.

CanIsubmitclaimsfordependentcareexpensesthataregreaterthanthecurrentbalance ofmyDependentCareFSA?

Yes,however,youwillonlyreceivereimbursementfortheamountthatyouhavecontributedto yourDependentCareFSA.Forexample,ifyoucontribute$150eachmonthtoyourDependent CareFSA,thenyouwillonlyreceive$150inreimbursementeachmonth.Theexcessamountof expenseswillbependedandautomaticallypaidtoyouascontributionsarepostedtoyour account.

WhathappensifaclaimexceedstheamountcurrentlyavailableinmyDependentCare FSA?

Theclaimwillbeprocessedandapproved.Theamountthatiscurrentlyavailablewillbe disbursedandtheremainingportionwillbependeduntilyoumakeanothercontribution.

HowdoI knowthatyoureceivedmyclaimandwhetherornotitwaspaid?

Generally,within twobusinessdaysofsubmittingaclaim,youcanviewyouraccountto check onthestatus oftheclaimat Spending Account /Health Reimbursement underemployee/participantandfollowtheon-screeninstructions.

WhencanIexpecttoreceivemyreimbursement?

Claimsaregenerallyprocessedwithintwobusinessdaysofreceipt.Reimbursementsarethen processedandreleasedaccordingtothedisbursementscheduleandfundingoptionofthe employer.Generally,disbursementschedulesaredaily.Thismeansthatreimbursementsare processedeachdayandincludeanyclaimsthatwereprocessedthepreviousday.Therelease ofyourreimbursementdependsuponthefundingoptionchosenbytheemployer.

HowdoI knowwhatmyaccountbalanceis?

Youcanuseoneofthefollowingmethodstocheckyouraccountbalance:

You can view your account at Simply choose Flexible Spending Account/ Health Reimbursement under Employee/Participants and follow the on-screen instructions.
You can view your balance on the mobile app.
Your account balance will be displayed on the reimbursement check or direct deposit notification each time you submit a claim.
You will receive a Balance Statement quarterly during the Plan year. This statement provides a summary of your remaining balance in the Health FSA and/or the Dependent Care FSA as well as claims paid to date.

HowdoI knowwhymyclaimwasdenied?

Youwillreceivealetterindicatingthereasonforthedenialalongwithinstructionsforsubmitting therequesteddocumentation.

Whymaytheamountofmyreimbursementdifferfromtheamountofmyrequest?

Therearereasonsthatyoumayseeadifferentreimbursementamount.For example:

Iftherequestwasformorethanthebalanceofyouraccount.

Annualelection / $1,000.00
Totalamountdisbursedtodate / $700.00
Availablebalance / $300.00
Totalamountofrequest / $500.00

Youwillonlybereimbursed$300.00,asthisisyouravailablebalance.

Iftherequestwasforadependentcareclaim,youmayonlybereimbursedforthetotal amountthatyouhavecontributed.

Annualelection / $5,000.00
Totalamountcontributed / $3,000.00
Totalamountofrequest / $4,250.00

Youwillonlybereimbursed$3,000.00,asthisistheamountthatyouhavecontributedtothe account.Theentirerequestof$4,250.00,willbeprocessedandtheremaining$1,250.00willbe disbursedascontributionsaremade.

15 E. Washington St. • PO Box 488 • Coldwater, MI 49036-0488 • 866-370-3040 • Fax: 800-379-5670 • E-mail:

ReimbursementForm

Employeename: IDorSSN: Employer: Address:

□addresschange

Daytimephone: Email:

Pleaseseereversesideforinstructionsand documentationrequirements.Asignedanddatedreimbursementformmustaccompanyeveryclaim.

Health FSA/Health ReimbursementArrangement(HRA)

Submittedclaimsmustinclude:

•Patient name•Provider nameand address

•Expenseincurred (typeof service)•Dateofincurred expense(dateserviceisprovided,notpaid)

•Amountofexpense•Amountinsurancepaid,ifapplicable

HRA: Your HRA planmaylimitthetypesof health careexpensesthatmay bereimbursed.PleasereadyourHRA plan’s

SummaryPlanDescription(SPD)for eligibleexpenses.

□ProcessmyhealthcareclaimsundertheHRAandtheHealthFSAbenefits.

DateofService
m/d/ytom/d/y / Patient name / Relationship / Account
(FSA, HRA) / Service
(i.e., medical, dental, vision) / OTCdrug
name / OTCdrug
purpose (e.g., allergies) / Amount
Requestedamount / $

□BennyCardusedforthisclaim□Useclaimstooffseta BennyCardtransactionclaim

Dependent Care FSA

Dependentmustbeundertheageof13tobeeligibleor an adultwhois a qualifying relativethatis disabled.The expensemusthappen toallow you and/or spousetowork.

DateofService
m/d/ytom/d/y / Dependent name / Relationship / Age / Provider name / Amount
I certifyI providedcareasspecified. / Requestedamount / $
Dependentcare provider signature(requiredwhen receiptnotprovided) / Date

I certifythat:

1.Theexpenseslistedhave beenincurred byme,myspouseormyeligibledependents(asdefined bytheIRS.

2.Allapplicableinsuranceorothermedicalplan benefitshavebeenexhausted.

3.ListedOTC expensesareto treata medicalcondition.

4.I will not deductthesereimbursementsasa taxcreditonmyfederalincometaxreturn.I have not beenreimbursedforandwill notsee reimbursementof,thelistedexpensesunderanyotherplancoveringsuchexpenses.

5.I willassumeall responsibilityfortaxesor penaltiesarisingout ofany disalloweddeductions.

6.I havereceivedthe taxpayerID numberofmydependentcareprovider.I understandthatI mustprovidethisinformationonmyfederal

incometaxreturn.

7.All servicesforwhichreimbursementor paymentisclaims by submissionofthisformwereprovidedduringa periodwhilethe

undersignedwascoveredunderthecompany’sFSAand/orHRAwithrespectto suchexpenses.

8.Tothebestofmyknowledge,all statementsonthisformaretrue,correctandcomplete.

Employeesignature(Youmustsign thisformtobereimbursed.)

Infinisource has incorporated theHIPAA Privacy requirements toreflect our business practice regardingyour insurance coverage.

15 E. Washington St. • PO Box 488 • Coldwater, MI 49036-0488 • 866-370-3040 • Fax: 800-379-5670 • E-mail:

Reimbursementinstructionsanddocumentationrequirements

Pleasereadthe instructionsbefore completingthisform.

1. / Completeall requiredinformation. / 4.Keepcopiesoftheformanddocumentationforyourtaxrecords.
2. / Youmustsignanddatetheform. / 5.Mailto Infinisource,PO Box488,Coldwater,MI49036orfaxto800-379-5670.
3. / Youmustattachrequireddocumentation.

The IRS doesnotallowcheckcopies, charge slipsorbalancestatementsasacceptabledocumentation.See#3 belowfor orthodontiarequirements. Youmaycombinefamilymembersononeform.Youmust submit separatereimbursementformsfor different planyears.

Documentationrequirementsfor HealthCare expensereimbursement

1.Medicalordentalexpenses Ifprocessedbyyourmedicalplan,pleasesubmittheexpensestothemedicalplanadministratororinsurance

carrierfirst.ThensubmitthisformandanExplanationofBenefitscontainingallthesupportingdocumentation. Proofofexpensepayment is notrequired.

2.Ifyoudonothavemedicalplancoveragefordentalorvisionexpenses,submitanitemized statement fromtheprovidershowingthepatient name,providernameandaddress,dateofservice,descriptionofservice andamountcharged. Forreimbursement ofcontactlenssolutions andcleaners,submitacashregisterreceiptdescribingtheitem.Ifthereceiptdoesnotdescribetheitem,provideacopyofthepackage indicatingpriceandproduct name.

3.Orthodontia

a.Ifyourplanprohibitsadvancepaymentfororthodontiaexpense,submitacopyoftheTruthinLendingStatement,orthodontiacontractor financialagreementwithyourinitialsubmissionitemizingthetreatmentperiod, downpayment,monthlypaymentamountandtheamount coveredbyinsurance,ifany.Ifthisisarecurringexpense,pleaseindicateandpaymentwillbeautomaticallymadeonamonthlybasis. Submita copyofyourmonthlypaymentcouponand/oritemizedreceipt eachtimeyourequestreimbursementforongoingtreatment. NOTE:theplancanreimburseorthodontiaexpensespaidinadvance.Thepaymentdatedeterminesplanyear.Additionalfeessuchasx- rays,molds,etc.,arereimbursablewhenincurred. Thebandingfee(attachingbrackets/bandsonteeth)canbepaidinfullwhenincurred. Downpaymentsare reimbursedafterbeing paidand banding hastakenplace. Pleasesubmitanitemizedreceiptshowingdownpayment.

b. Ifyour planallowsadvancepaymentfororthodontiaexpenses,pleasesubmita copy showingpaymentfororthodontia.

4.Prescriptions Submitacopyofthereceiptshowingpatientname,drugname,dateprescriptionwasfilledandco-paymentamountcharged.

Cashregisterprescription receipts orchargeslipsshowingtheprescription andamountcharged cannotbeaccepted,asthepatientnameand drugnameor numberarerequired.

5.OTCexpenses Youmustindicatethedrugnameanditspurposetotreatthepatient.AllOTCdrugclaimsmustbeaccompaniedbyan itemizedreceipt.Cashregisterreceiptsmustincludeprovidernameandaddress,purchasedate,OTCexpensename(ifthedrug/medicine nameisnotonthecashregisterreceipt,submitthepackageportionwiththedrug/medicine nameandpricewiththecashregister receipt). NOTE: someOTCdrugsarenoteligibleforreimbursement unlessaspecificmedicalconditionexists.Ineligibledrugreimbursementrequests (cosmeticreasons[Rogaine],weightloss,generalhealth[vitamins])mustincludeaphysicianrecommendationforthepurchaseandlista medicalcondition.

EffectiveJanuary1,2011,OTCmedicinesordrugsarenoteligibleforreimbursedunderHealthFlexibleSpendingAccounts(FSA)orHRAs

withouta doctor’sprescription.

Documentationrequirementsfor DependentCare reimbursement

1.CompleteFSAReimbursementForm,haveprovider signanddateandsubmitto Infinisource,or

2.CompleteFSAReimbursementFormandattachdocumentationwhichmustincludeprovidernameandaddress,dependentname,service datesandexpenseamount.Acancelledcheckisinsufficient documentation.

IMPORTANT

•Claimsmustbefullyincurred beforereimbursement.Infinisourcecannot processclaimsforfuture datesofserviceexceptasindicatedabove.

•Someexpensesassociatedwith dependentcareare not eligible(overnightcamp,foodandtransportationcosts).Ifyouaresubmittingcharges fora daycamp, documentationmust show thatitisa daycamp.

•YourmustprovidetheIRSwiththename,addressandtaxIDorSocialSecurityNumberofthedependentcareprovideronyourfederal incometaxreturn.Ifyouareunableto providethisinformation,theIRSmaydenythe exclusionforthedependentcarespendingaccount.

Claimsappeal

Ifyourclaimisdeniedinwholeorinpart,youmayappealbyrequesting review ofthe deniedclaim. Yourrequestmustbeinwritingand mustbe submittedinaccordance with theinstructionssetforthinthedenialnoticewithin180daysafteryoureceive noticeofthedenial. Iftherearetwo levelsofappeal,youwillhaveareasonableamountoftimeasdescribedinthedenialnoticeinwhichtorequestasecondreviewbytheplan administrator. Youwillbenotifiedinwritingofthereviewdecisionassoonasreasonablypossible,butnolaterthan60daysafterthereview requestisreceived.Your SPDoutlinesthisinmoredetail.

Claimconfirmation

Youcanviewyour claimstatus 24/7at loginandthen selectFSA or HRA Participant). Ifyoumailyourclaim, donotfax it. Faxclaimsto800-379-5670andkeeptheconfirmationforyourrecords. Allowtwobusinessdaysbeforecheckingthewebsite orcallingforthe statusoffaxedclaims.

15 E. Washington St. • PO Box 488 • Coldwater, MI 49036-0488 • 866-370-3040 • Fax: 800-379-5670 • E-mail:

FSAEnrollment

Planyearbeginning Ending Checkone:NewenrollmentRe-enrollment

Employer: Division(if applicable):

Employeename:Soc.Sec.No:

LastFirstMI

Date ofbirth:Homeaddress:

City:State:Zip:E-mail:

PayrollFrequency: / Weekly (52) / Biweekly (26) / Semimonthly (24) / Monthly (12) / Other
Date ofhire: / Effective date:

Paycheckdeductionsstarton:NumberofdeductionsinthePlanyear:

Enter the annualamount ofyour allocation(s) for thePlanYear totheaccount(s) ofyour choiceanddivide bythenumberof paychecks youreceive duringthePlanYear to arrive attheamountofyour salaryreductioneach paycheck.
Annual
Benefit Elections:Election
A. DependentCareFlexibleSpendingAccount(FSA)
(Thisamountcannotexceed$5,000perfamilypercalendaryear; $2,500 if married filing separately)$
B. HealthFlexibleSpendingAccount (FSA) $
(This amount cannotexceed$2,550 per plan year)
C. Limited Purpose/Post-deductible Health FSA $
(This amount cannotexceed $2,550 per calendar year)
TotalAuthorizedPre-taxSalaryReductions$
 Waiver of ParticipationinHealthFSAandDependentCareFSA.
Aftercarefulconsideration, Ihavechosennot toparticipate intheFSAs forthecurrent PlanYear
D. PremiumPayment (Pre-tax)
Contributions totheemployer-sponsoredbenefit plan(s).Per PayPeriod$ *
 Waiver of ParticipationinPre-taxPremiumPayment.
Aftercarefulconsideration, Ihavechosennot toparticipate inthepre-taxpremiumportionof thePlan.
*This amount canbeautomatically increasedor decreasedduringthe PlanYear tocorrespondwithincreasesor decreasesintheamountof Employee contributionsrequired byEmployer toits benefitplans.
By signingbelow,I understandthat:
• I am authorizingmy employer toreducemycompensationbytheamount specified.
• I understandthat I am not permittedtochangemyelections duringthePlanYearunless thechangeis onaccount of andconsistent withcurrent recognized IRS
regulations andchangeinstatus events.
•I also understand that unused account balances in my Dependent Care and Health FSAs at the end of the Plan Year or Plan’s grace period are subject to forfeiture, based on applicable IRS law and regulations and Plan design.
EmployeeSignature: / Date:

Infinisource,Inc. has incorporatedthe HIPAAPrivacyRequirementsto reflectour organization’sbusinesspracticesregardingyourFSAcoverage.

15 E.Washington St.• PO Box488•Coldwater,MI49036-0488•866-370-3040• Fax: 800-379-5670 • E-mail: