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HomeMy Public PortalAbout2018.09.13 NueSynergy Contract - Benefit Admin NueSynergy® I•E Intc CUSTOMER FOCUSED • TECHNOLOGY DRIVEN Dear IntegraFlex Benefits Client, We are pleased to announce our upcoming merger with NueSynergy. It is scheduled to take place officially on September 1, 2018.On that date our combined firm will begin conducting its practice as NueSynergy. IntegraFlex began its professional practice in 2003 with its growth over the past 15 years being predominantly internal, stemming from the referrals of our client base and those of other professionals. Our growth has also been in no small way related to the success our clients have had in their business and personal pursuits. We have decided to seek a merger with NueSynergy because we believe that a larger organization will allow us to provide a wider array of services. IntegraFlex conducted an extensive search within our region looking for an opportunity like this. NueSynergy exceeded our hopes for an organization we can combine with and continue the tradition we have for excellent service,extensive expertise, and an environment our clients and team members want to be a part of.A larger organization will also mean our team members will benefit from more and stronger career opportunities. NueSynergy shares the same values as IntegraFlex;with NueSynergy's tag line being—Customer Focused and Technology Driven. Beginning in 1996, NueSynergy has grown to become one of the largest benefit account administrators in the area. In addition to many innovations, like single platform administration and insurance carrier integration, NueSynergy has stayed consumer-focused and value-driven. Many new services and areas of expertise will be provided in the future and we look forward to discussing those in more depth with you.There are, however,a few things we want to point out that will not change: • You will continue to work with the same Idaho staff,which are being retained in their current roles and you will be introduced to a designated account manager and team,who have the expertise,experience,and state-of-the-art technology to provide faster and accurate responses. • For the time being, our fee structure will not change with the services you have been provided in the past continuing to be offered. The NueSynergy office resides at-4601 College Blvd.,Suite 280, Leawood, KS 66211.Although our existing phone numbers continue to be operational for now,we anticipate consolidating phone numbers in the future and will provide ample notice prior to any consolidation. The Idaho staff will remain here in Idaho with our contact information remaining the same except our e-mail addresses will change on or around September 1.The convention for the addresses will be [first initial][lastname]@nuesynergy.com. If you have any questions about this exciting news and what it will mean for you, please contact any of us at any time.We look forward to introducing you to our new partner and team members. We are grateful to you not only for giving us the opportunity to provide you with third party administrative management and business solutions for your consumer-driven tax-advantaged plans and COBRA, but for your loyalty and friendship, which have enriched our relationship.We are confident that our new affiliation will serve us all well. Sincerely, Keith S. Paduch {> IntegraFlex, CEO Josh Collins NueSynergy, President [ ,, ` ►f. NueSynergy® f .4of CUSTOMER FOCUSED • TECHNOLOGY DRIVEN { Our priority is to ensure a smooth transition to NueSynergy for both you and your participating employees. While we are providing you with access to many new services, we will handle the transition work and make it as easy and effortless for you. For example, • employee participants will continue to access their account through the Integra Flex Portal, • the current IntegraFlex debit card will remain active, • in addition to the continued support of the IntegraFlex team, there will be increased customer service and dedicated account managers to be supporting your plan, • additional plan features such as carrier claims integration will be available for your plans in the months to come, and • you will continue to have access to the same admin portal and reports. If you have any questions, feel free to call us at 913.653.8381. Includes the following documents (in order): 1. Debit Card Settlement ACH Authorization Release Form (2 pages) 2. Employer ACH Authorization-Signature Verification Form (1 page) 3. W-9 (4 pages) 4. NueSynergy Business Associates Agreement (5 pages) 5. Contract Assignment Agreement (1 page) Signatures needed on: • Page 1 of the Debit Card Settlement ACH Authorization Release Form • Employer ACH Authorization-Signature Verification Form • W-9 • Page 5 of Business Associates Agreement • Contract Assignment Agreement NueSynergy, Inc. 4601 College Blvd. Ste. 280 Leawood, KS 66211 Phone: 913.653.8381, Toll-Free: 855.890.7239, Fax: • - NueSynergy® 855.890.7238 Email: employersupport@NueSynergy.com } Debit Card Settlement ACH Authorization Release Form T 3 Employers:A business card of the signatory and a voided check(if checks are drawn from the account)should accompany this form,or the program live date may be delayed.Once completed,please provide to your benefits administrator. ❑ New Customer ❑� Current Customer—Update Only City of McCall HEREBY authorizes FIS or FIS'agent to initiate ACH (Group/Employer Name) (automated clearing house)transfer entries for debit card daily settlement for the following depository: Financial Institution Name: US Bank Address: City: McCall State: ID Zip code: 83638 Routing and Transit No: count No: Type of Account (Please check one): s Account By signing below,you authorize FIS or FIS'agent to initiate ACH(automated clearing house)transfer entries for Acknowledgement Statement daily debit card settlement.Furthermore,by signing you acknowledge your receipt and acceptance of the FIS Policy for ACH failures. Information Provided by Linda K Stokes (Please print your name): Signature:l� ! *111 Title: Treasurer, Finance Director Today's Date: 09/13/2018 ADMINISTRATION USE ONLY Verified by administrator Implementation: Verification Date: Date to Set-Up: Date Settlement Set-Up: Bank Account and Settlement Bank Account Filters • It is common for financial institutions to provide a bank account filter for commercial bank accounts.A filter aids • in blocking ACH debits not approved by the bank account owner.If the bank account owner has established a filter,the below information should be provided to them in order for ACH debits to occur on behalf of card settlements. Table 2:M&I Bank Filter Information 'Al&1 Bank Filter Information for IIS Ilealthcarc Pdvnicnts Solution. Submitting Bank(ODFI) M&I BANK Company Name(Account Name) Metavante Routing Number Origination ID Company ID Tax ID Important:It is important to remember that there is a$1.00 ACH debit performed at the creation of each bank account loaded within our platform to ensure that it is a valid bank account.Please ensure that the bank account is active and there is at least$1.00 in the account at the time the employer banking account information is provided.This$1.00 debit is non-refundable. Daily Settlement Monday through Saturday at 3:45 PM Central Time,MasterCard®or VISA®send a"call for funds"to all of its processors, including FIS's processors for all card transactions processed the previous 24 hours;this is known as the"Settlement Date"of the transaction(See Table 3: Settlement Timeline).FIS's processor pays MasterCard®or VISA®in total. Note:FIS is not responsible for paying the merchant.This is the responsibility of MasterCard®or VISA®or the merchant Acquirer. Once the individual settlement amounts are calculated,FIS's processor submits an ACH request for the daily transaction amount to the bank account on file for the individual employer group to recoup the funds already paid on the employer's behalf. The ACH debit is generated via the Federal Reserve Banking System and generally funds are withdrawn from the employer account within 12-24 hours.If funds are not made available to pay the ACH debit,FIS reserves the right to temporarily inactivate all cards under that particular employer until funds are paid. Important:All returned ACH's are subject to a return fee of$25 per rejection.FIS will provide timely information should an ACH debit be rejected,and will resubmit the ACH debit.If funds are not made available to pay the ACH debit,FIS reserves the right to temporarily inactivate all cards under that particular employer until funds are paid. Table 3: Settlement Timeline 1CII Debit Posted to I.:1111)1o\ Srttlentent Take. Place in BPS ;AC1I File to I:edictal Reserve I Group 1)esi2uatcri Bank ;Account Monda Monda Tuesda Tuesda Tuesda Wednesda Wednesda Wednesda Thursda Thursda Thursda Frida Frida Frida Monda Saturda Sunda Monda Sunda Sunda Monda ACH Authorization/Signature Verification Form If NueSynergy is drafting manual reimbursements and/or initiating direct deposits as part of our FSA administrative services,we need proof of authorization as both a protection for our client and NueSynergy. Based on the services we perform for your company,the following sections need to be completed: ❑� Section One: ACH Authorization(grants NueSynergy permission to process ACH debit/credit entries) ❑ Section Two: Signature Verification (authorizes NueSynergy to draft checks with the signature of an approved company representative) Important: It is important to remember that there is a$1.00 ACH debit performed at the creation of each bank account loaded within our platform to ensure that it is a valid bank account.Please ensure that the bank account is active and there is at least$1.00 in the account at the time the employer banking account information is provided.This $1.00 debit is non-refundable. Section One: Authorization Agreement for Direct Pa 'ments (ACH Debits) Employer Group:City of McCall Financial Institution: US Bank Branch: McCall, IDaho City: McCall State: ID Zip:836378 Bank Routing Nun Account Number: I hereby authorize NueSynergy to initiate debit entries from the financial institution and corresponding account listed above and,if necessary,debit or credit entries for adjustments due to error in association with the FSA administration services.This authorization is to remain in full force and effect until NueSynergy receives written notification that such authorization has been revoked and has a reasonable opportunity to act on it. NueSynergy has the right to terminate or suspend the agreement for breach of ACH Rules within 10 days. NueSynergy also has the right to audit the Client's compliance with this Agreement and the ACH Rules.PLEASE ATTACH A COPY OF A VOIDED CHECK FROM YO. ' B K ACCOUNT. i09/13/2018 Signature —• _ Date: Section Two: Signature Verification The following signature should be printed on all FSA reimbursement checks for the above company.Please submit or attach a copy of a Signature Card from your financial institution that corresponds with the signature below acknowledging that the facsimile signature is authorized with your Financial Institution. Please use a black felt tip pen when signing for best reproduction results. SIGN IN SPACE PROVIDED DATE N /A PRINT NAME DATE N /A NueSynergy, Inc. 4601 College Blvd. Ste. 280 Leawood,KS 66211 Phone: 913.653.8381, Toll-Free: 855.890.7239, Fax: 855.890.7238 Email: customerservice NueS ner com @ y �. NueSynergy Form W-9(Rev.8-2013) Page 2 In the cases below,the following person must give Form W-9 to the partnership Updating Your Information for purposes of establishing its U.S.status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business You must provide updated information to any person to whom you claimed to be in the United States: an exempt payee if you are no longer an exempt payee and anticipate receiving •In the case of a disregarded entity with a U.S.owner,the U.S.owner of the reportable payments in the future from this person.For example,you may need to disregarded entity and not the entity, provide updated information if you are a C corporation that elects to be an S corporation,or if you no longer are tax exempt.In addition,you must furnish a new •In the case of a grantor trust with a U.S.grantor or other U.S.owner,generally, Form W-9 if the name or TIN changes for the account,for example,if the grantor the U.S.grantor or other U.S.owner of the grantor trust and not the trust,and of a grantor trust dies. •In the case of a U.S.trust(other than a grantor trust),the U.S.trust(other than a Penalties grantor trust)and not the beneficiaries of the trust. Foreign person.If you are a foreign person or the U.S.branch of a foreign bank Failure to furnish TIN.If you fail to furnish your correct TIN to a requester,you are that has elected to be treated as a U.S.person,do not use Form W-9.Instead,use subject to a penalty of$50 for each such failure unless your failure is due to the appropriate Form W-8 or Form 8233(see Publication 515,Withholding of Tax reasonable cause and not to willful neglect. on Nonresident Aliens and Foreign Entities). Civil penalty for false information with respect to withholding.If you make a Nonresident alien who becomes a resident alien.Generally,only a nonresident false statement with no reasonable basis that results in no backup withholding, alien individual may use the terms of a tax treaty to reduce or eliminate U.S.tax on you are subject to a$500 penalty. certain types of income.However,most tax treaties contain a provision known as Criminal ena for falx a"saving clause."Exceptions specified in the saving clause may permit an P ItY falsifying information.Willfully falsifying certifications or • exemption from tax to continue for certain types of income even after the payee affirmations may subject you to criminal penalties including fines and/or has otherwise become a U.S.resident alien for tax purposes. imprisonment. If you are a U.S.resident alien who is relying on an exception contained in the Misuse of TINS.If the requester discloses or uses TINs in violation of federal law, saving clause of a tax treaty to claim an exemption from U.S.tax on certain types the requester may be subject to civil and criminal penalties. of income,you must attach a statement to Form W-9 that specifies the following five items: Specific Instructions 1.The treaty country.Generally,this must be the same treaty under which you claimed exemption from tax as a nonresident alien. Name 2.The treaty article addressing the income. If you are an individual,you must generally enter the name shown on your income 3.The article number(or location)in the tax treaty that contains the saving tax return.However,if you have changed your last name,for instance,due to • clause and its exceptions. marriage without informing the Social Security Administration of the name change, 4.The type and amount of income that qualifies for the exemption from tax. enter your first name,the last name shown on your social security card,and your new last name. 5.Sufficient facts to justify the exemption from tax under the terms of the treaty If the account is in joint names,list first,and then circle,the name of the person article. or entity whose number you entered in Part I of the form. Example.Article 20 of the U.S.-China income tax treaty allows an exemption Sole proprietor.Enter your individual name as shown on your income tax return from tax for scholarship income received by a Chinese student temporarily present on the"Name"line.You may enter your business,trade,or"doing business as in the United States.Under U.S.law,this student will become a resident alien for (DBA)"name on the"Business name/disregarded entity name"line. tax purposes if his or her stay in the United States exceeds 5 calendar years. However,paragraph 2 of the first Protocol to the U.S.-China treaty(dated April 30, Partnership,C Corporation,or S Corporation.Enter the entity's name on the 1984)allows the provisions of Article 20 to continue to apply even after the "Name"line and any business,trade,or"doing business as(DBA)name"on the Chinese student becomes a resident alien of the United States.A Chinese student "Business name/disregarded entity name"line. who qualifies for this exception(under paragraph 2 of the first protocol)and is Disregarded entity.For U.S.federal tax purposes,an entity that is disregarded as relying on this exception to claim an exemption from tax on his or her scholarship an entity separate from its owner is treated as a"disregarded entity." See or fellowship income would attach to Form W-9 a statement that includes the ,Regulation section 301.7701-2(c)(2)(ii).Enter the owner's name on the"Name" information described above to support that exemption. line.The name of the entity entered on the"Name"line should never be a If you are a nonresident alien or a foreign entity,give the requester the disregarded entity.The name on the"Name"line must be the name shown on the appropriate completed Form W-8 or Form 8233. income tax return on which the income should be reported.For example,if a foreign LLC that is treated as a disregarded entity for U.S.federal tax purposes What is backup withholding?Persons making certain payments to you must has a single owner that is a U.S.person,the U.S.owner's name is required to be under certain conditions withhold and pay to the IRS a percentage of such provided on the"Name"be subjectline.If the direct owner of the entity is also a disregarded payments.This is called"backup withholding." Payments that may to entity,enter the first owner that is not disregarded for federal tax purposes.Enter backup withholding include interest,tax-exempt interest,dividends,broker and the disregarded entity's name on the"Business name/disregarded entity name" barter exchange transactions,rents,royalties,nonemployee pay,payments made line.If the owner of the disregarded entity is a foreign person,the owner must in settlement of payment card and third party network transactions,and certain complete an appropriate Form W-8 instead of a Form W-9. This is the case even if payments from fishing boat operators.Real estate transactions are not subject to the foreign person has a U.S.TIN. backup withholding. Note.Check the appropriate box for the U.S.federal tax classification of the r You will not be subject to backup withholding on payments you receive if you whose name is entered on the"Name"line(Individual/sole proprietor, give the requester your correct TIN,make the proper certifications,and report all person personPartnershi your taxable interest and dividends on your tax return. P.C Corporation,S Corporation,Trust/estate). Limited Liability Company(LLC).If the person identified on the"Name"line is an Payments you receive will be subject to backup LLC,check the"Limited liability company"box only and enter the appropriate withholding if: code for the U.S.federal tax classification in the space provided.If you are an LLC • that is treated as a partnership for U.S.federal tax purposes,enter"P"for i 1.You do not furnish your TIN to the requester, partnership.If you are an LLC that has filed a Form 8832 or a Form 2553 to be 2.You do not certify your TIN when required(see the Part II instructions on page taxed as a corporation,enter"C"for C corporation or"S"for S corporation,as j 3 for details), appropriate.If you are an LLC that is disregarded as an entity separate from its 3.The IRS tells the requester that you furnished an incorrect TIN, owner under Regulation section 301.7701-3(except for employment and excise tax),do not check the LLC box unless the owner of the LLC(required to be 4.The IRS tells you that you are subject to backup withholding because you did identified on the"Name"line)is another LLC that is not disregarded for U.S. not report all your interest and dividends on your tax return(for reportable interest federal tax purposes.If the LLC is disregarded as an entity separate from its and dividends only),or owner,enter the appropriate tax classification of the owner identified on the r, 5.You do not certify to the requester that you are not subject to backup "Name"line. `; withholding under 4 above(for reportable interest and dividend accounts opened Other entitles.Enter your business name as shown on required U.S.federal tax f after 1983 only). documents on the"Name"line.This name should match the name shown on the charter or other legal document creatingthe entity.You mayenter anybusiness, f Certain payees and payments are exempt from backup withholding.See Exempt e9 payee code on page 3 and the separate Instructions for the Requester of Form trade,or DBA name on the"Business name/disregarded entity name"line. W-9 for more information. '- Also see Special rules for partnerships on page 1. Exemptions If you are exempt from backup withholding and/or FATCA reporting,enter in the s, What is FATCA reporting?The Foreign Account Tax Compliance Act(FATCA) Exemptions box,any code(s)that may apply to you.See Exempt payee code and requires a participating foreign financial institution to report all United States Exemption from FATCA reporting code on page 3. account holders that are specified United States persons.Certain payees are exempt from FATCA reporting.See Exemption from FATCA reporting code on page 3 and the Instructions for the Requester of Form W-9 for more information. z Form W-9(Rev.8-2013) Page 3 Exempt payee code.Generally,individuals(including sole proprietors)are not G—A real estate investment trust exempt from backup withholding.Corporations are exempt from backup H—A regulated investment company as defined in section 851 or an entity withholding for certain payments,such as interest and dividends.Corporations are registered at all times during the tax year under the Investment Company Act of not exempt from backup withholding for payments made in settlement of payment 1940 card or third party network transactions. Note.If you are exempt from backup withholding,you should still complete this I—A common trust fund as defined in section 584(a) form to avoid possible erroneous backup withholding. J—A bank as defined in section 581 The following codes identify payees that are exempt from backup withholding: K—A broker 1—An organization exempt from tax under section 501(a),any IRA,or a L—A trust exempt from tax under section 664 or described in section 4947(a)(1) custodial account under section 403(b)(7)if the account satisfies the requirements M—A tax exempt trust under a section 403(b)plan or section 457(g)plan of section 401(f)(2) 2—The United States or any of its agencies or instrumentalities Part I.Taxpayer Identification Number(TIN) 3—A state,the District of Columbia,a possession of the United States,or any of Enter your TIN in the appropriate box.If you are a resident alien and you do not their political subdivisions or instrumentalities have and are not eligible to get an SSN,your TIN is your IRS individual taxpayer 4—A foreign government or any of its political subdivisions,agencies,or identification number(ITIN).Enter it in the social security number box.If you do not instrumentalities have an ITIN,see How to get a TIN below. 5—A corporation If you are a sole proprietor and you have an EIN,you may enter either your SSN or EIN.However,the IRS prefers that you use your SSN. 6—A dealer in securities or commodities required to register in the United of the United States If you area single-member LLC that is disregarded as an entity separate from its States,the District of Columbia,or a possessionowner(see Limited Liability Company(LLC)on page 2),enter the owner s SSN(or 7—A futures commission merchant registered with the Commodity Futures EIN,if the owner has one).Do not enter the disregarded entity's EIN.If the LLC is Trading Commission classified as a corporation or partnership,enter the entity's EIN. 8—A real estate investment trust Note.See the chart on page 4 for further clarification of name and TIN 9—An entity registered at all times during the tax year under the Investment combinations. Company Act of 1940 How to get a TIN.If you do not have a TIN,apply for one immediately.To apply 10—A common trust fund operated by a bank under section 584(a) for an SSN,get Form SS-5,Application for a Social Security Card,from your local 11—A financial institution Social Security Administration office or get this form online at www.ssa.gov.You may also get this form by calling 1-800-772-1213.Use Form W-7,Application for 12—A middleman known in the investment community as a nominee or IRS Individual Taxpayer Identification Number,to apply for an ITIN,or Form SS-4, custodian Application for Employer Identification Number,to apply for an EIN.You can apply 13—A trust exempt from tax under section 664 or described in section 4947 for an EIN online by accessing the IRS website at www.irs.gov/businesses and clicking on Employer Identification Number(EIN)under Starting a Business.You The following chart shows types of payments that may be exempt from backup can get Forms W-7 and SS-4 from the IRS by visiting IRS.gov or by calling 1-800- withholding.The chart applies to the exempt payees listed above,1 through 13. TAX-FORM(1-800-829-3676). IF the payment is for... THEN the payment is exempt for... If you are asked to complete Form W-9 but do not have a TIN,apply for a TIN and write"Applied For"in the space for the TIN,sign and date the form,and give it • to the requester.For interest and dividend payments,and certain payments made • Interest and dividend payments All exempt payees except with respect to readily tradable instruments,generally you will have 60 days to get for 7 a TIN and give it to the requester before you are subject to backup withholding on payments.The 60-day rule does not apply to other types of payments.You will be Broker transactions Exempt payees 1 through 4 and 6 subject to backup withholding on all such payments until you provide your TIN to through 11 and all C corporations.S the requester. • corporations must not enter an exempt Note.Entering"Applied For"means that you have already applied for a TIN or that payee code because they are exempt you intend to apply for one soon. only for sales of noncovered securities acquired prior to 2012. Caution:A disregarded U.S.entity that has a foreign owner must use the appropriate Form W-8. Barter exchange transactions and Exempt payees 1 through 4 patronage dividends Part II. Certification To establish to the withholding agent that you are a U.S.person,or resident alien, Payments over$600 required to be Generally,exempt payees sign Form W-9.You may be requested to sign by the withholding agent even if reported and direct sales over$5,0001 1 through 52 items 1,4,or 5 below indicate otherwise. For a joint account,only the person whose TIN is shown in Part I should sign Payments made in settlement of Exempt payees 1 through 4 (when required).In the case of a disregarded entity,the person identified on the payment card or third party network "Name"line must sign.Exempt payees,see Exempt payee code earlier. transactions Signature requirements.Complete the certification as indicated in items 1 1See Form 1099-MISC,Miscellaneous Income,and its instructions. through 5 below. :However,the following payments made to a corporation and reportable on Form 1.Interest,dividend,and barter exchange accounts opened before 1984 1099-MISC are not exempt from backup withholding:medical and health care and broker accounts considered active during 1983.You must give your payments,attorneys'fees,gross proceeds paid to an attorney,and payments for correct TIN,but you do not have to sign the certification. services paid by a federal executive agency. 2.Interest,dividend,broker,and barter exchange accounts opened after Exemption from FATCA reporting code.The following codes identify payees 1983 and broker accounts considered inactive during 1983.You must sign the that are exempt from reporting under FATCA.These codes apply to persons certification or backup withholding will apply.If you are subject to backup submitting this form for accounts maintained outside of the United States by withholding and you are merely providing your correct TIN to the requester,you certain foreign financial institutions.Therefore,if you are only submitting this form must cross out item 2 in the certification before signing the form. for an account you hold in the United States,you may leave this field blank. 3.Real estate transactions.You must sign the certification.You may cross out Consult with the person requesting this form if you are uncertain if the financial item 2 of the certification. institution is subject to these requirements. 4.Other payments.You must give your correct TIN,but you do not have to sign A—An organization exempt from tax under section 501(a)or any individual the certification unless you have been notified that you have previously given an retirement plan as defined in section 7701(a)(37) incorrect TIN."Other payments"include payments made in the course of the B—The United States or any of its agencies or instrumentalities requester's trade or business for rents,royalties,goods(other than bills for merchandise),medical and health care services(including payments to C—A state,the District of Columbia,a possession of the United States,or any corporations),payments to a nonemployee for services,payments made in of their political subdivisions or instrumentalities settlement of payment card and third party network transactions,payments to D—A corporation the stock of which is regularly traded on one or more certain fishing boat crew members and fishermen,and gross proceeds paid to established securities markets,as described in Reg.section 1.1472-1(c)(1)() attorneys(including payments to corporations). E—A corporation that is a member of the same expanded affiliated group as a 5.Mortgage interest paid by you,acquisition or abandonment of secured corporation described in Reg.section 1.1472-1(c)(1)(i) property,cancellation of debt,qualified tuition program payments(under a F—A dealer in securities,commodities,or derivative financial instruments section 529),IRA,Coverdell ESA,Archer MSA or HSA contributions or distributions,and pension distributions.You must give your correct TIN,but you (including notional principal contracts,futures,forwards,and options)that is do not have to sign the certification. registered as such under the laws of the United States or any state : 1. i Form W-9(Rev.8-2013) Page 4 What Name and Number To Give the Requester Note.If no name is circled when more than one name is listed,the number will be Give name and SSN of For this type of account considered to be that of the first name listed. 1.Individual The individual Secure Your Tax Records from Identity Theft 2.Two or more individuals(joint The actual owner of the account or, Identity theft occurs when someone uses your personal information such as your account) if combined funds,the first name,social security number(SSN),or other identifying information,without your individual on the account' permission,to commit fraud or other crimes.An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund. 3.Custodian account of a minor The minor (Uniform Gift to Minors Act) To reduce your risk: 4.a.The usual revocable savings The grantor-trustee •Protect your SSN, trust(grantor is also trustee) •Ensure your employer is protecting your SSN,and b.So-called trust account that is The actual owner' •Be careful when choosing a tax preparer. not a legal or valid trust under If your tax records are affected by identity theft and you receive a notice from state law the IRS,respond right away to the name and phone number printed on the IRS 5.Sole proprietorship or disregarded The owner notice or letter. entity owned by an individual If your tax records are not currently affected by identity theft but you think you 6.Grantor trust filing under Optional The grantor' are at risk due to a lost or stolen purse or wallet,questionable credit card activity Form 1099 Filing Method 1(see or credit report,contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Regulation section 1.671-4(b)(2)(I)(A)) Form 14039. For this type of account Give name and EIN of: For more information,see Publication 4535,Identity Theft Prevention and Victim 7.Disregarded entity not owned by an The owner Assistance. individual Victims of identity theft who are experiencing economic harm or a system 8.A valid trust,estate,or pension trust Legal entity' problem,or are seeking help In resolving tax problems that have not been resolved 9.Corporation or LLC electing The corporation through normal channels,may be eligible for Taxpayer Advocate Service(TAS) corporate status on Form 8832 or assistance.You can reach TAS by calling the TAS toll-free case intake line at Form 2553 1-877-777-4778 or TTY/TDD 1-800-829-4059. 10.Association,club,religious, The organization Protect yourself from suspicious emails or phishing schemes. Phishing is the charitable,educational,or other creation and use of email and websites designed to mimic legitimate business tax-exempt organization emails and websites.The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user 11.Partnership or multi-member LLC The partnership into surrendering private information that will be used for identity theft. 12.A broker or registered nominee The broker or nominee The IRS does not initiate contacts with taxpayers via emails.Also,the IRS does 13.Account with the Department of The public entity not request personal detailed information through email or ask taxpayers for the Agriculture in the name of a public PIN numbers,passwords,or similar secret access information for their credit card, entity(such as a state or local bank,or other financial accounts. government,school district,or If you receive an unsolicited email claiming to be from the IRS,forward this prison)that receives agricultural message to phishing@irs.gov.You may also report misuse of the IRS name,logo, program payments or other IRS property to the Treasury Inspector General for Tax Administration at 14.Grantor trust filing under the Form The trust 1-800-366-4484.You can forward suspicious emails to the Federal Trade 1041 Filing Method or the Optional Commission at:spam@uce.gov or contact them at www.ftc.gov/idtheft or 1-877- Form 1099 Filing Method 2(see IDTHEFT(1-877-438-4338). Regulation section 1.671-4(b)(2)(i)(B)) Visit IRS.gov to learn more about identity theft and how to reduce your risk. List first and circle the name of the person whose number you furnish.If only one person on a joint account has an SSN,that person's number must be furnished. z Circle the minor's name and fumish the minor's SSN. 'You must show your individual name and you may also enter your business or"DBA"name on the'Business name/disregarded entity"name line.You may use either your SSN or EIN(if you have one),but the IRS encourages you to use your SSN. 4 List first and circle the name of the trust,estate,or pension trust.(Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.)Also see Special rules for partnerships on page 1. *Note.Grantor also must provide a Form W-9 to trustee of trust. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons(including federal agencies)who are required to file information returns with the IRS to report interest,dividends,or certain other income paid to you;mortgage interest you paid;the acquisition or abandonment of secured property;the cancellation of debt;or contributions you made to an IRA,Archer MSA,or HSA.The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information.Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities,states,the District of Columbia,and U.S.commonwealths and possessions for use in administering their laws.The information also may be disclosed to other countries under a treaty,to federal and state agencies to enforce civil and criminal laws,or to federal law enforcement and intelligence agencies to combat terrorism.You must provide your TIN whether or not you are required to file a tax return.Under section 3406,payers must generally withhold a percentage of taxable interest,dividend,and certain other payments to a payee who does not give a TIN to the payer.Certain penalties may also apply for providing false or fraudulent information. ) BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement(this"Agreement"), entered into as of Sept. 13, 2018 is between City of McCall and NueSynergy, Inc. (the"Business Associate"and,together with the Covered Entity,the"Parties")in order to address the requirements of the HIPAA Security and Privacy Rules with respect to"Business Associates." WHEREAS,the Business Associate and its representatives are, or will be,performing certain functions, activities and services to or on behalf of the Covered Entity as defined within a separate"Adoption Agreement,"and both Parties are subject to the requirements of HIPAA; NOW,THEREFORE, in connection with the creation,receipt,maintenance,transmission,use or disclosure of"Protected Health Information"(as defined in Section V. and referred to herein as"PHI")as a Business Associate(as defined in the Section V)of the Covered Entity,the Parties hereby agree as follows: I. OBLIGATIONS AND ACTIVITIES OF THE BUSINESS ASSOCIATE The Business Associate acknowledges that it is required by law to comply with all applicable requirements of the HIPAA Security and Privacy Rules,and all additional security requirements of the Health Information Technology for Economic and Clinical Health Act(the"HITECH Act"),Title XIII of the American Recovery and Reinvestment Act of 2009 (ARRA),that are applicable to"Business Associates"(as defined in the HIPAA Security and Privacy Rules). Therefore,the Business Associate agrees to: 1. Create, receive,maintain,transmit,use or disclose PHI only in a manner that is consistent with the Agreement or as required by law. In providing services to or on behalf of the Covered Entity,the Business Associate,for example,may use and disclose PHI for treatment,payment and healthcare operations. Such instances include,but are not limited to: adjudicating claims,preparing reimbursements for qualified health care expenses; and preparing reports related to account balances, funding requirement and other activities needed to support the Plan's obligations. 2. Use appropriate safeguards,and establish,implement and maintain administrative,physical and technical safeguards that comply with Subpart C of 45 CFR Part 164 with respect to ElectronicPHl, to prevent use or disclosure of PHI other than as provided for by the Agreement. 3. Report to the Covered Entity any use or disclosure of PHI not provided by the Agreement of which it becomes aware, including Breaches of Unsecured PHI as required by 45 CFR 164.410,and any Security Incident of which it becomes aware. a. In the event of a Breach or potential Breach by the Business Associate of Unsecured PHI, as the terms"breach"and"unsecured PHI"are defined in 45 CFR 164.402,the Business Associate shall report such Breach or potential Breach to the Covered Entity within ten(10) business days of becoming aware of such Breach or potential Breach.The Business Associate's report shall include all information available to the Business Associate as necessary to allow the Covered Entity to provide a notification of the Breach consistent with 45 CFR 164.404. 4. Require each agent, including a Subcontractor,who creates, receives, maintains or transmits PHI on behalf of the Business Associate,to agree to the same restrictions, conditions and requirements that apply to the Business Associate with respect to such information. 5. Make PHI available in a Designated Record Set to or on behalf of the Covered Entity as necessary to satisfy the Covered Entity's obligations under 45 CFR 164.524 within ten(10)business days of receipt of such request.The Business Associate may deny such requests, if the requested information is meant to be shared with the Employer of a Health Plan and is for more than Summary Health Information. 6. Make any amendment(s)to PHI in a Designated Record Set as agreed to by the Covered entity pursuant to 45 CFR 164.526, or take other measures as necessary to satisfy the Covered Entity's obligations under 45 CFR 164.526. 7. Maintain and make available the information required to provide an accounting of disclosures to or on behalf of the Covered Entity as necessary to satisfy the Covered Entity's obligations under 45 CFR 164.528. The Business Associate shall not be required to maintain a record of disclosures of PHI(1) made for the purpose of Treatment,Payment or Healthcare Operations,(2)made to an individual who is the subject of the PHI, or(3)made pursuant to an authorization that is valid under HIPAA. 8. Make its internal practices,books and records available to the"Secretary"for purposes of determining compliance with HIPAA rules. 9. Disclose PHI to report violations of law to appropriate Federal or State authorities. 10. In performing its obligations under this Agreement and the Adoption Agreement,use, disclose or request only the minimum necessary PHI to accomplish the intended purpose of the use, disclosure or request. 11. Acknowledge and agree that from time to time the Department of Health and Human Services may modify the standard transactions now identified in 45 CFR 162.1101-162.1802.The Business Associate and its agents and Subcontractors agree to abide by any changes to such standard transactions that are applicable to the services defined in the Adoption Agreement. Permitted Uses and Disclosures of PHI 1. Business Associate may only use or disclose PHI needed to perform the duties set forth in the Adoption Agreement for the treatment, payment or health care operations of the Covered Entity. 2. Business Associate may use or disclose PHI as required by law. 3. Business Associate may use or disclose PHI for the proper management and administration of Business Associates,or to carry out the legal responsibilities of the Business Associate,provided the disclosures are required by law, or Business Associate obtains reasonable assurances from the person to whom the information is disclosed that the information will remain confidential and used or further disclosed only as required by law for the purposes for which it was disclosed to the person, and the person notifies the Business Associate of any instances of which it is aware that confidentiality of the information has been breached. 2 Restriction on Uses and Disclosures 1. Business Associate shall not use or disclose PHI in a manner that would violate the Privacy Rule. 2. Business Associate shall not release or sell individual PHI to engage in marketing or fundraising activities without prior authorization from the individual. 3. Business Associate shall not disclose to a Subcontractor or otherwise allow a Subcontractor to access PHI until the Subcontractor enters in its own agreement with Business Associate to abide by the administrative,physical and technical safeguards that reasonably protect the confidentiality, integrity and availability of electronic PHI in compliance with the Security Rules. II. OBLIGATIONS OF THE COVERED ENTITY 1. Covered Entity shall notify Business Associate of any limitation(s)in the Notice of Privacy Practices of covered entity under 45 CFR 164.520,to the extent that such limitation may affect Business Associate's use or disclosure of PHI. 2. Covered Entity shall notify Business Associate of any changes in, or revocation of,the permission by an individual to use or disclose his or her PHI,to the extent that such changes may affect Business Associate's use or disclosure of PHI. 3. Covered entity shall notify Business Associate of any restriction on the use or disclosure of PHI that Covered Entity has agreed to or is required to abide by under 45 CFR 164.522,to the extent that such restriction may affect Business Associate's use or disclosure of PHI. III.TERM AND TERMINATION 1. This Agreement shall be effective as of the date first set forth above and shall terminate as provided in Section 1II.3 below or when all PHI previously provided by the Covered Entity to the Business Associate, or created or received by the Business Associate on behalf of the Covered Entity, is destroyed or returned to the Covered Entity. • 2. Upon either Party's knowledge or reasonable belief that the other Party is in or has committed a Breach or violation of any material obligation set forth in this Agreement that is required pursuant to 45 CFR 164.314(a)(2)(i)or 45 CFR 164.504(e)(2),the non-breaching party may: a. terminate this Agreement with immediate effect by delivering written notice of such termination to the breaching party regardless of whether such Breach is continuing at the time the non- breaching party delivers such notice;or b. require the breaching party to demonstrate that it has taken appropriate steps that are, in the non- breaching party's sole discretion,reasonably designed to prevent a recurrence of such Breach. 3. Obligations of the Business Associate upon termination. Upon termination of this Agreement pursuant to Section II1.2,the Business Associate shall promptly return to the Covered Entity, or, if agreed to by the Covered Entity,destroy, all PHI previously created,maintained or received by the Business Associate on behalf of the Covered Entity that the Business Associate maintains in any form. The Business Associate shall retain no copies of such PHI. 3 4. Retention of PHI. The Business Associate may retain PHI to the extent reasonably necessary to permit the Business Associate to comply with applicable laws and so long as the Business Associate extends the protections of this Agreement to all such PHI and takes all actions necessary to limit further uses and disclosures of such PHI for so long as the Business Associate retains such PHI. If the Covered Entity and the Business Associate determine in good faith that termination of this Agreement and the return or destruction of all PHI previously provided by the Covered Entity to the Business Associate would cause irreparable business interruption or harm to the Covered Entity, or if termination of this Agreement is otherwise not feasible,then(1)the Covered Entity or the Business Associate may report such situation to the Secretary of Health and Human Services and(2)the Business Associate shall extend the protections of this Agreement to all such PHI and limit further uses and disclosures of such PHI to those purposes that make the return or destruction infeasible,for so long as the Business Associate maintains such PHI. Upon termination of the condition that makes retention of PHI by the Business Associate necessary for the Business Associate's compliance with law or that makes return or destruction of PHI infeasible,the Business Associate shall return or destroy such PHI as instructed by the Covered Entity. 5. Survival. The obligations of the Business Associate under this Section III shall survive the termination of this Agreement. IV. LEGAL PROVISIONS t t I. Indemnification. Each Party(an"Indemnifying Party") shall,to the fullest extent permitted by law, protect,defend, indemnify and hold harmless the other Party and such other Party's employees, directors and agents(each, an"Indemnitee")from and against any and all losses, costs,claims, penalties,fines, demands, liabilities, legal actions,judgments and expenses of every kind(including reasonable attorneys' fees, including at trial and on appeal)asserted or imposed against any Indemnitee arising out of the acts or omissions of the Indemnifying Party or any Subcontractor or consultant of the Indemnifying Party or any of the Indemnifying Party's employees, directors or agents related to any material Breach of this Agreement or negligent failure to comply with HIPAA. 2. Amendment. The Covered Entity and the Business Associate may amend this Agreement by mutual written consent. 3. Severability. If any provision of this Agreement is held invalid or unenforceable,such invalidity or unenforceability shall not invalidate or render unenforceable any other portion of this Agreement.The entire Agreement will be construed as if it did not contain the particular invalid or unenforceable provision(s),and the rights and obligations of the Business Associate and the Covered Entity will be construed and enforced accordingly. 4. Waiver. The failure by one Party to require performance of any provision of this Agreement shall not affect such Party's right to require performance at any time thereafter,nor shall a waiver of any Breach or default of this Agreement constitute a waiver of any subsequent Breach or default or a waiver of the provision itself. 5. Entire Agreement. This Agreement supersedes and replaces any and all prior Business Associate Agreements between the Parties. To the extent that the Adoption Agreement addresses the rights and obligations contained in this Agreement,this Agreement supersedes and replaces all provisions in the Adoption Agreement related to the subject matter of this Agreement. 4 tr V.DEFINITIONS "Breach"shall generally have the same meaning given to such term under 45 CFR 164.402. "Designated Record Set"shall generally have the same meaning given to such term under 45 CFR 164.501. "HIPAA Rules" shall generally have the same meaning as the Privacy, Security, Breach Notification, and Enforcement Rules under 45 CFR Part 160 and Part 164. "Protected Health Information" or"PHI"shall generally have the same meaning given to such term under 45 CFR 160.103. "Secretary" shall generally mean the Secretary of the United States Department of Health and Human Services. "Security Incident" shall generally have the meaning given to such term under 45 CFR 164.304. Capitalized terms used but not defined in this Agreement shall have the meaning given to such terms in the HIPAA Privacy and Security Rules. IN WITNESS WHEREOF,the parties execute this Agreement by their duly authorized representatives as the date set forth above. • NueSynergy, Inc. September 13, 2018 (Business Associate) *ver-d ) • d I. By: ✓� By: • Name: Josh Collins Name: Robert S. Giles Title: President Title: Council President 5 3 CONSENT TO ASSIGNMENT OF SERVICE AGREEMENTS The undersigned (the "Employer") and Integrated Disability Management, Inc. d/b/a IntegraFlex ("IntegraFlex") have entered into a certain Service and Facilitation Agreement and/or COBRA Administration Service Agreement (the "Service Agreements"), copies of which are attached hereto. IntegraFlex desires to assign the Service Agreements to NueSynergy, Inc.("NueSynergy"). The Employer hereby consents to the assignment of the Service Agreements attached hereto to NueSynergy by IntegraFlex. This Consent is dated /3 Cert-Piv1k018. EMPLOYER: By: .%/(4/7 /�i Authorized Officer/Representative 1Uu.✓1Lc. ( Pre Sic& { {32979/68122;816744. }