17-1106 Fifth Third Bank HSA Services FIFTH THIRD BANK
HSA SERVICES AGREEMENT
This HSA Services Agreement ("Agreement") is hereby made and entered into this
l_9 day of N o J c-w41W, 2017, ("Effective Date") by and between FIFTH THIRD
BANK, an Ohio banking corporation, located at 38 Fountain Square Plaza, Cincinnati, Ohio
45263 ("Fifth Third") and The City of Elgin, an Illinois municipal corporation, located at 150
Dexter Court Elgin, IL 60120 ("Employer").
1. Fifth Third HSA Account Services.
(a) Fifth Third has agreed, through itself, its affiliates, and third party service
providers'(collectively "Fifth Third") to act as the custodian of health savings accounts ("HSA"),
and provide certain related debit card and other administrative services as set forth in attached
Schedule A (collectively "HSA Account Services") to individuals employed by the Employer
("Employees") who:
(i) are participants in a high deductible health plan ("HDHP"), as defined
under Section 223 of the Internal Revenue Code of 1986, as amended (the
"Code"),
(ii) wish to establish an HSA, and
(iii) designate Fifth Third to serve as the custodian and recordkeeper for their
HSA.
Employees who enroll in a Fifth Third HSA are referred to herein as "Account
Beneficiaries" and their accounts are referred to as "HSA Custodial Accounts."
(b) Employees who desire to establish an HSA Custodial Account must execute Fifth
Third's then current HSA Custodial Account Agreement ("Custodial Account Agreement").
(c) Fifth Third shall have absolute discretion with respect to whether and under what
circumstances it shall establish, administer, suspend and/or terminate an HSA Custodial Account
or any transaction in connection therewith. Except as expressly set forth in this Agreement, an
applicable Custodial Account Agreement, or as may be required by applicable law, Fifth Third
shall have no responsibility with respect to contributions paid by Employer, Account
Beneficiaries or other contributors or transferors to the HSA Custodial Accounts, other than to
receive the contributions paid or transferred to Fifth Third and allocate them among the HSA
Custodial Accounts in accordance with instructions received from the Employer. Fifth Third
shall have no obligation to take affirmative actions to collect monies paid as contributions, such
as, for example, to pursue a check from Employer or an Account Beneficiary or other contributor
or transferor that does not clear. To the extent that the allocation instructions provided to Fifth
Third with respect to contributions are ambiguous -to Fifth Third, Fifth Third shall undertake
reasonable steps to obtain additional information to clarify the ambiguity. In the event that Fifth
Third does not promptly receive information sufficient to clarify the ambiguity, Fifth Third in its
discretion may take such acts as it deems appropriate with respect to such contributions,
including, without limitation, returning the contributions to Employer.
(d) Fifth Third shall be entitled to rely on any information or instructions from
Employer, Account Beneficiaries or any other third party retained or acting on behalf of or for
the benefit of any of them, and shall have no obligation to verify or confirm the accuracy or
completeness thereof, and shall have no responsibility for any actions or inactions taken in
accordance with any such instructions received by Fifth Third.
(e) Fifth Third and Employer shall each comply with all federal, state and local laws
and regulations applicable to its performance under this Agreement.
2. HSA Custodial Accounts.
(a) It is agreed that the Account Beneficiary shall be the account holder of(with an
ownership interest in) the HSA Custodial Account established with Fifth Third. It is further
agreed that Employer shall not be the account holder or have any ownership interest in the HSA
Custodial Accounts, nor shall Employer be a party to any contract or agreement between Fifth
Third and the Account Beneficiary, including but not limited to Custodial Account Agreements.
(b) The assets in the HSA Custodial Accounts shall be invested in accordance with
the provisions of the applicable Custodial Account Agreement. Fifth Third may, in its discretion,
make available to Account Beneficiaries the ability to invest the monies in their HSA Custodial
Accounts in such other investment options as are permissible by law.
(c) With respect to any investment options that are made available to Account
Beneficiaries under their Custodial Account Agreements, the decision with respect to the manner
m which the HSA Custodial Account assets are invested shall be made solely by the Account
Beneficiary. Additional agreements may be required of Account Beneficiaries before they can
invest in the investment options that may be made available to Account Beneficiaries in addition
to the interest bearing demand deposit account.
(d) Employer acknowledges and agrees that:
(i) Fifth Third has no authority or control over HSA Custodial Accounts,
except as expressly provided in the Custodial Account Agreements
between Fifth Third and Account Beneficiaries;
(ii) Fifth Third is not a fiduciary with respect to HSA Custodial Account
assets or administrator, plan sponsor, trustee or a fiduciary of any HDHP
or other employee benefit plan;
(iii) Fifth Third has no obligation to confirm or verify that Account
Beneficiaries are eligible to establish HSAs in accordance with Section
223 of the Code;
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(iv) Fifth Third is not responsible or liable for verifying or determining that
any direction or instruction of Account Beneficiaries complies with or
satisfies any legal, regulatory or accounting requirement applicable
thereto, including whether distributions out of an Account Beneficiary's
HSA are for qualified medical expenses;
(v) Fifth Third is not obligated to confirm or verify that the HDHP satisfies
the requirements of Section 223 of the Code; and
(vi) Fifth Third has no obligation to ensure that contributions to an Account
Beneficiary's HSA do not exceed the maximum annual contribution limit.
3. Employer Obligations.
(a) Employer represents and warrants that the group health plan sponsored and
maintained by Employer pursuant to which medical coverage is provided to Account
Beneficiaries will be, at all times relevant to this Agreement, an HDHP, in accordance with
Section 223 of the Code. Employer agrees that it will comply with all of its obligations under
Section 223 of the Code and other applicable laws in connection with or related to the HSA
Custodial Accounts.
(b) It is the intention and understanding of the parties hereto that the HSA Custodial
Accounts do not constitute employee benefit plans; and that the assets held in the HSA Custodial
Accounts are not plan assets subject to the provisions of the Employee Retirement Income
Security Act of 1974, as amended, ("ERISA"). Employer acknowledges and agrees that at all
times relevant to this Agreement, participation in HSAs by Employees shall be completely
voluntary; and Employer shall not:
(1) limit the ability of Account Beneficiaries to move monies in their HSAs to
another HSA (except to the extent of restrictions imposed or permitted by
the Code);
(ii) impose any conditions on the utilization of HSA Custodial Account
monies beyond those permitted by the Code;
(iii) represent or advise that the HSAs are an employee welfare benefit plan
established or maintained by the employer; or
(iv) receive any payment or compensation in connection with an HSA.
Employer agrees that it will advise Fifth Third as soon as practicable in the event that it becomes
aware of any facts or has reason to believe that the HSA Custodial Accounts may be subject to
ERISA. Employer understands and acknowledges that Fifth Third is not responsible for any
aspect of ERISA's participation, vesting, funding, reporting, disclosure, fiduciary requirements
or any other obligation that might apply to the extent such HSAs are deemed to be subject to
ERISA.
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(c) In order to enable Fifth Third to fulfill its obligations to establish and maintain a
Customer Identification Program ("CIP") pursuant to the USA Patriot Act, the Bank Secrecy
Act, the Money Laundering Control Act and all other applicable anti-money laundering laws,
now or hereafter existing, and all regulations promulgated pursuant thereto, as well as all rules,
rulings, interpretations, advisories, orders, decrees, guidelines, interpretations and applications
thereof, Employer shall follow those CIP procedures Fifth Third specifies from time to time.
(d) Employer shall not be entitled to recoup any contributions made by it to an HSA
Custodial Account, except for correction or errors and related adjustments which may be
processed at Fifth Third's discretion.
(e) Employer shall provide Fifth Third with such documents, instructions, and
information at such times and in such form and manner as may be requested by Fifth Third in
order for Fifth Third to provide the HSA Custodial Accounts and to ensure compliance with any
laws, regulations or statutes applicable to Fifth Third or the HSA Custodial Accounts. Employer
acknowledges that any delay in providing such documents, instructions and/or information to
Fifth Third may result in a delay or preclude Fifth Third from being able to provide the HSA
Account Services.
(fl Employer shall be responsible for the performance of services under this
Agreement by subcontractors, agents and representatives to the same extent as though such
services were performed by Employer pursuant to this Agreement.
(g) Employer agrees, to the extent possible to assist Fifth Third in the collection and
verification of Employee information necessary for the opening, maintenance and reporting of
Employee HSAs.
4. Information and Data Transmittal. Fifth Third is authorized to accept directions
and/or data transmitted to Fifth Third through the following means by Employees, or by the
Employer or its authorized representatives:
(a) Fifth Third is authorized to act on written direction or data transmissions
conveyed by facsimile transmissions, electronic mail or other electronic means notwithstanding
the fact that such directions or data do not bear an authorized signature, provided the directions
or data acted upon:
(i) appear to have been sent from the computer of a person, or by a person,
entitled to give binding directions to Fifth Third, and
(ii) are consistent with the established authority of such persons.
(b) Employer understands the risk associated with communicating time sensitive
matters, such as trade directions, by facsimile or electronic means and it acknowledges that, if it
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elects to do so, Fifth Third will act within a reasonable time of receipt of the facsimile or
electronic direction/data transmission. The Employer further acknowledges that directions and
data provided under this Agreement may be less confidential than directions and data transmitted
by other methods. Fifth Third shall not be liable for any loss of the confidentiality of directions
and data prior to receipt by Fifth Third.
(c) Fifth Third may rely fully on any facsimile or electronic transmission received by
it, and shall have no obligation to review or verify its accuracy.
5. Fees. Fifth Third may include in the Custodial Account Agreements with Account
Beneficiaries (to the extent consistent with applicable law) provisions authorizing and/or
requiring that the Account Beneficiaries authorize and direct Fifth Third to debit the Account
Beneficiaries' HSA Custodial Accounts for the fees payable by the Account Beneficiaries to
Fifth Third. Employer may pay the fees otherwise payable by the Account Beneficiaries'
pursuant to the Custodial Account Agreements. The current fees are set forth on Schedule B,
attached hereto and incorporated herein by reference. Fifth Third may change such fees at any
time without notice to Employer.
6. Intellectual Property. Neither party shall have the right to use any of the trademarks,
service marks, logos or other indicia of origin, of the other party unless the party owning such
names or mark(s) expressly consents in writing to such use. All software, materials, information,
processes, and products, including the Fifth Third websites and the contents thereof, used by
Fifth Third to perform services under this Agreement, all modifications made thereto, and Fifth
Third's work records are Fifth Third's or its third party licensors' proprietary information.
7. Limitation of Liability. Notwithstanding anything to the contrary contained in this
Agreement, neither Fifth Third nor Employer nor their respective affiliates shall, under any
circumstances, be liable to the other or their respective affiliates or any other party for any
consequential, incidental, indirect, punitive, exemplary, special or similar damages of any kind
or nature whatsoever (including damages relating to loss of profits, income, goodwill, or data),
even if Fifth Third or Employer or their respective affiliates have been apprised of the likelihood
of such damages occurring.
8. Indemnification. Employer hereby agrees to hold harmless and indemnify Fifth Third,
and Fifth Third's agents, affiliates, successors and assigns for and against any and all liabilities,
claims, costs, and damages of any nature (excluding any related legal fees) arising out of or
relating to any liability, claim, costs, expenses or damages that may directly or indirectly be
incurred as a result of Fifth Third's good faith efforts in following facsimile or electronic
direction/data transmissions received from Employer or its representatives and/or any reasonable
action or inaction of Fifth Third based on such facsimile or electronic transmissions received
from Employer or its representatives regarding the HSA Custodial Accounts or any breach of
this Agreement by Employer. This section does not apply to any cost or damage attributable to
Fifth Third's gross negligence or intentional misconduct. In addition, to the extent that
Employer's logo, name, slogan or other intellectual property ("Employer Intellectual Property")
is utilized by Fifth Third on a website, in marketing materials or otherwise, Employer hereby
agrees to indemnify, hold harmless and defend Fifth Third, and Fifth Third's agents, affiliates,
successors and assigns for and against any and all liabilities, claims, costs, expenses, and
damages of any nature (including any related legal fees) arising out of or relating to any liability,
claim, costs, expenses or damages that may directly or indirectly be incurred as a result of the
infringement or misappropriation, or alleged infringement or alleged misappropriation, of any
third party intellectual property or other rights to the extent that such infringement or
misappropriation is attributable to the Employer Intellectual Property.
9. Termination of Agreement.
(a) This Agreement shall be effective as of the Effective Date and shall continue in
effect thereafter until terminated in accordance with this Section. Either party may terminate this
Agreement without cause upon 90 days advance written notice to the other party.
Notwithstanding the foregoing, Fifth Third and Employer may terminate this Agreement at any
time with the express and mutual agreement of both parties.
(b) Notwithstanding subsection 9(a) above, Fifth Third may terminate this Agreement
immediately, and without prior written notice, if any of the following occur:
(i) Fifth Third determines, in its sole discretion, that any of the HSAs
established under this Agreement may be subject to ERISA;
(ii) Employer breaches any of the terms and conditions in this Agreement or
any other agreement it has with Fifth Third;
(iii) Employer, voluntarily or involuntarily, becomes the subject of any
bankruptcy, insolvency, reorganization or other similar proceeding; or
(iv) Employer experiences a material adverse change in its financial condition
or its ability to perform its obligations under the terms and conditions in
this Agreement.
(c) Upon termination of this Agreement, Fifth Third shall be entitled to payment for
all services rendered through the date of termination, and Employer and Fifth Third shall
promptly discontinue the use and distribution of the names, advertisements, literature, brochures,
trademarks, and other materials in any medium that refer to the party or suggest that this
Agreement is still in effect.
(d) The termination of this Agreement will not result in the termination of any
existing HSA Custodial Accounts established by Account Beneficiaries prior to the termination
date. The rights of such Account Beneficiaries and their relationship with Fifth Third are
established pursuant to the terms of the Custodial Account Agreement entered into between Fifth
Third and such Account Beneficiaries.
(e) The obligations of the parties under Sections 6, 7, 8, 9, 10, 11, 12, 14 and 15 shall
survive the expiration or termination of this Agreement.
10. Notices. Except as otherwise provided in this Agreement, all notices related to this
Agreement shall be:
(a) in writing,
(b) delivered by hand, overnight courier or by U.S. mail to the address prescribed by
this Agreement and
(c) deemed given three business days following deposit, postage paid, into the U.S.
Postal system in the event that they are sent by mail. Either Employer or Fifth
Third may change its address for notice by giving written notice thereof to the
other.
11. HIPAA. With respect to the HSA services being provided under this Agreement and the
Custodial Account Agreements, Employer understands and acknowledges that Fifth Third is not
a "covered entity," "business associate" or "plan sponsor" as those terms are defined by the
Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). The fact that Fifth
Third may be a business associate with respect to other services provided under other agreements
should not be construed to mean that Fifth Third is a business associate for purposes of HSA
services. Fifth Third expressly disclaims responsibility for duties imposed on covered entities
and plan sponsors under HIPAA.
12. Assignment and Subcontracts. Either party may assign this Agreement:
(a) to any entity directly or indirectly controlling, controlled by, or under common
control with such party, or
(b) to the successor (by sale, merger, reorganization or otherwise) to the business
operations of such party. Fifth Third may employ subcontractors or enter into alliances with third
parties to perform all or any part of the services under this Agreement.
13. Force Majeure. The parties shall be excused from performance of their respective
obligations pursuant to this Agreement for any period and to the extent that it is prevented from
performing such obligations, in whole or in part, as a result of delays caused by the other or a
third party (except agents of the other party), or an act of God, or any other cause over which the
non-performing party does not have direct control, including Internet or communication
problems, third party hardware or software errors, computer viruses or similar harmful programs
or data, or unauthorized access or theft.
14. Confidentiality. Employer agrees that all information about HSA customers of Fifth
Third provided by Fifth Third to Employer as well as any and all information regarding Fifth
Third's products and services provided under this Agreement shall be deemed confidential and
proprietary to Fifth Third. Employer shall not use such information for any purpose other than as
required for the performance of Employer's obligations under the Agreement and may disclose
such information to its employees, agents and subcontractors on a "need to know" basis for the
sole purpose of the performance of Employer's obligations hereunder. Employer shall not allow
such information to be accessed by any third party, including an affiliate of Employer or a
permitted subcontractor, without the written agreement of such third party to be bound by the
terms of this section 14. ; provided, however, that Employer's compliance with the requirements
of the Illinois Freedom of Information Act (5 ILCS 140/1, et seq.) shall not be construed so as to
constitute a breach of this Agreement, and Employer shall not be liable to Fifth Third for any
damages resulting from or arising out of Employer's good faith efforts to comply with any
applicable law.
15. General.
(a) No amendment or change to this Agreement shall be valid unless in writing and
signed by authorized representatives of the parties.
(b) This Agreement constitutes the entire agreement between the parties with respect
to the subject matter hereof, and there are no representations, understandings or agreements
relative hereto which are not fully expressed herein. This Agreement supersedes all prior
agreements, written or oral, with respect to such subject matter. There are no third party
beneficiaries of this Agreement.
(c) The invalidity or unenforceability of any provision of this Agreement shall not
affect the other provisions, and this Agreement is to be construed in all respects to the extent
possible to fulfill the purposes of this Agreement with the omission of such invalid or
unenforceable provision.
(e) This Agreement may be executed in counterparts, each of which shall be
an original and all of which shall constitute one and the same Agreement. For the purposes of
executing this Agreement, any signed copy of this Agreement transmitted by fax machine or e-
mail shall be treated in all manners and respects as an original document. The signature of any
party on a copy of this Agreement transmitted by fax machine or e-mail shall be considered for
these purposes as an original signature and shall have the same legal effect as an original
signature. Any such faxed or e-mailed copy of this Agreement shall be considered to have the
same binding legal effect as an original document. At the request of either party any fax or e-
mail copy of this Agreement shall be re-executed by the parties in an original form. No party to
this Agreement shall raise the use of fax machine or e-mail as a defense to this Agreement and
shall forever waive such defense.
IN WITNESS WHEREOF, this Agreement has been executed and delivered by the
parties hereto as of the last date executed below.
FIFTH THIRD BANK EMPLOYER:
By: By:
Title: VP Fifth Third Bank Title:
Date: 11-2-2017 Date:
FAI-egal Dept\Agreement\Fifth Third HSA Services Agr-redlined-10-27-17.docx
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Schedule A
Fifth Third Bank
HSA Account Services
This Schedule A sets forth the HSA-related services that Fifth Third Bank will provide to
Employer under this Agreement:
(1) Provide Employees with access to Fifth Third's HSA product, including its HSA
custodial services which are more fully described in the HSA Custodial Account Agreement.
(2) Use commercially reasonable efforts to market Fifth Third's HSA product to
Employees, including but not limited to distributing relevant HSA materials to Employees and
conducting Employee meetings to review and discuss such material.
(3) Make available to Employees HSA management tools, and HSA education,
enrollment and application processes and information through the online system established by
Fifth Third, and/or through other methods made available by Fifth Third, including but not
limited to, availability by phone of Fifth Third personnel to address Employees' questions and
concerns regarding HSA enrollment and operation.
(4) Facilitate the transfer to Fifth Third of HSA contributions from Employees and/or
Employer, including but not limited to automated transfers and payroll deductions.
(5) Provide Employees with access to their HSA funds in accordance with the HSA
Custodial Account Agreement. Such access may include the following:
• Debit card that Employee may use at point of sale terminals as set forth in
applicable cardholder agreements and related documents.
• Direct reimbursement to health care providers identified by Employee.
• Direct reimbursement to Employee's personal checking or savings account
designated by Employee.
(6) Provide the following reports to Employer regarding HSAs established by
Employees with Fifth Third:
• Identification of such Employees.
• Aggregate contributions to all such HSAs.
• Other information that Fifth Third may, in its discretion, provide from time to
time to the extent permitted by law.
(7) Prepare tax reporting with respect to HSA contributions and distributions as
required by the Code and applicable law.
Schedule B
RFTH THIRD SANK
The curious bank.
Fifth Third Pricing and Services at a Glance
Simple. Straightforward, Transparent.
Minimum Deposit Needed $0
to Open Account
Health Savings Account: Online(Self)Enrollment':$5.00 Waived
One-time Enrollment Charge' Enrollment by Employer':$10.00 Waived
Paper Application':$20.00
Health Savings Account: Average daily balance<$5002:$3.50
Monthly Service Charge Average daily balance$500.01-$2,0002:$3.00
Average daily balance$2,000.01-$3,0002:$2.50
Average daily balance$3,000.01-$4,0002:$2.00
Employer Paid Average daily balance<$4,000.00: $2.00
Health Savings Account: Average daily balance greater than$4,000.00
Requirements to Waive Monthly Service Charge
Interest Rate The Fifth Third Bank HSA Cash Account is a deposit account
that is FDIC-insured up to the maximum amount permitted
by law and earns a competitive rate of interest. Any
interest earned on contributions to an HSA accumulates
tax-free.
The interest rate earned in your HSA Cash Account will only
be applicable to the cash amount in each respective tier.
HSA Cash Interest Minimum Maximum
Account Rate Annual Annual
Daily Percentage Percentage
Balance Yield(APY) Yield(APY)
$0.01- .25% .25%APY .25%APY
$2,000
>$2,000.01 .40% .25%APY .40%APY
As of March 1,2017
ATM Fees—Fifth Third $0
Non Fifth Third ATM Transactions No fee assessed by Fifth Third Bank;fees may be assessed
by the ATM operator.
HSA Checks $24.99
Box of 50
Account Closure Fee $25.00'*
Outgoing Rollover Fee $25.00'*
Account Information
Copy of statement Per Request $5 per copy
(retrieve existing statement)
Copy of Check Per Request $5 per copy
Payment Information
Stop Payment Fee $33 per item.
Debit Card Services
HSA Debit MasterCard $0 for the first two cards
Card Replacement Fee $10 each
Other
Mutual Fund Participation $2"
Monthly Fee
Funds Availability Policy Electronic Direct Deposits and Wire Transfers—Same
When funds deposited to your account are available. Business Day we receive the deposit.
Check/Cash Deposit at ATM prior to cut-off time-Up to
$100 of the total of your check deposits for the day will be
available on the day we receive the deposit. Remaining
funds will be available on the first Business Day after the
day we receive your deposit.
* In some situations we may notify you after your deposit
is made that your funds will not be available for up to 8
business days.
A Business Day is a non-holiday weekday.Funds received
after certain cut-off times may be credited the next
business day.
Please see Rules and Regulations brochure for details.
Error Resolution In Case of Errors or Questions About Your Electronic Transfers:
Electronic transactions and to report lost/stolen cards Telephone Us:
or password,unauthorized transfers. 1-888-350-5353
Write us:
Fifth Third Bank
Attention:HSA Operations
5050 Kingsley Drive
MD 1MOC2G
Cincinnati,OH 45263
Please see Rules and Regulations brochure for details.
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HAVE QUESTIONS?Call: 1-888-350-5353 or click www.53hsa.com.
Interest rates effective as of March 1,2017
'If your account is opened through an Employer-based plan
The Fifth Third Bank HSA Cash Account earns interest. Please then your Employer or TPA may pay your One-time
request a Rate Sheet or visit 53.com for the interest rates and Enrollment Fee. Please refer to your Employer-provided
annual percentage yields.The Bank may change the interest benefits information to understand if your Employer pays this
rate and annual percentage yield (APY) at any time without fee for you.
notice. Your interest begins to accrue no later than the
business day we receive credit for the deposit of non-cash Z If your account is opened through an Employer-based plan
items (for example, checks). Interest on your account will be then your Employer or TPA may pay your Monthly HSA Service
compounded continuously and credited monthly. The Bank Fee. Please refer to your Employer-provided benefits
uses the daily balance method to calculate interest on your information to understand if your Employer pays this fee for
account. This method applies a daily periodic rate to the you.If your employment is terminated for any reason,you will
balance in your account each day. When your account is be responsible for payment of the Monthly HSA Service Fee
closed you will forfeit any accrued interest. which is currently set based on the balance in your
account.Please refer to the Health Savings Account Monthly
Fifth Third Bank pays the stated interest rate and annual Service Charge section on page 1.
percentage yield (APY) only on that portion of the balance
within the specified tier.The Annual Percentage Yield Earned 3 Fee is charged and deducted at the time the account is
(APYE) during a statement period is an annualized rate that closed or rolled over to another institution. Accounts without
reflects the relationship between the daily balance and the transactional activity within 180 days of account opening will
amount of interest actually earned on the account within the automatically be closed. Any account maintaining a $0.00
applicable tier(s). balance for 16 consecutive months will automatically be
closed.The fee will be the lesser of$25.00 or the remaining
Annual Percentage Yield accurate as of date listed in Interest balance in your account at time of closure/rollover request.
Information. Rates may change after the account is opened.
Fees may reduce earnings. "Please refer to each individual Prospectus for fees related to
each Mutual Fund available through the Fifth Third Bank HSA
Fifth Third Bank may change the amount or type of any of the Investment Options. A balance of$2,000 in the HSA Cash
above fees or add additional fees at any time in accordance Account is required before investing in mutual funds. An
with the terms of the Health Savings Custodial Account Investment Administration Fee totaling 20 basis points
Agreement. annually will be assessed. (Basis points are typically used to
measure interest rates and other financial percentages.This
fee will be applied to your HSA Investment Account at the end
of each calendar quarter in increments of 5 basis points,or
0.05%of the total average balance in your investment
account. (One basis point equals 1/100`h or 0.01%of your
total average investment account balance.) Mutual funds are
not insured by the FDIC;are not deposits with,obligations of
or guaranteed by Bell Bank,Fifth Third Bank or any other
bank;and are subject to investment risk,including possible
loss of the principal amount invested.
'.Depostarid credit products.provided by Fifth ThN Bank Mr:f b�FDIC.The,standard deposit hsuranoe wnour�l Is 525a000 per depositor.Prose'see.
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Health Savings Account Employer Setup Form
Section 1:Company Information
The City of Elgin
Tax ID: 36-6005862
150 Dexter Court
Elgin
IL
60120
Section 2: HSA Online Portal User Information
Day to Day Contact: 'Addtl Online User(optional)-'
Name Gail Cohen
Title/Position HR Director
E-Mail Address cohen_g @cityofelgin.org
Telephone Number 847-931-5607
Section 3: HSA Plan Summary
HSA Plan Year Start Date (mm/dd/yyyy format): 1-1-2018
Will Employer contribute to Employee HSAs? Yes ® No ❑
Total Number of Insurance-Eligible Employees: 700
Number of Insurance Plans Offered: 2
Section 4a: Employer Funding Account Section 4b: Employer Fee Account
Complete if you will initiate HSA Payroll Deductions Complete if you will pay any HSA fees on behalf of your
and/or HSA Employer Contributions Employees
Bank Name Bank Name:
Routing Number: Routing Number'
Account Number: 3' 'Account Number
Account Type: Checking ® Savings ❑ Account Type: Checking ❑ Savings ❑
Section 5: HSA Fee Information
Designate fee amount& responsibility(Employer or Employee)by checking appropriate boxes below
One-time Enrollment Charge
Online: $0.00 Employer ❑ Employee
By Employer: $0.00 Employer ❑ Employee
Paper: $20.00 Employer ❑ Employee
Monthly Service Charge: $2.00
® Flat Employer Paid Employer ® Employee ❑
Effective Date of Fees (mm/dd/yyyy format): 1-1-2018
HSA SERVICES AGREEMENT
ADDENDUM
This Addendum to the HSA Services Agreement (this "Addendum") is between Fifth Third
Bank, an Ohio banking corporation ("FTB"), and the "Employer") whose name, authorized
signature and address appear on the Signature Page to this Addendum, and is dated the "Effective
Date") set forth on the Signature Page. Capitalized terms not defined in this Addendum, shall
have the meaning attributed to them in the HSA Services Agreement (the "Agreement"). The
Agreement remains in full force and effect and this Addendum is in addition to the provisions
contained therein.
Employer has advised FTB that, instead of having employees accept terms and conditions in the
FTB consumer portal, Employer desires to offer employees the opportunity to establish Health
Savings Accounts ("HSA") contemplated by the Agreement by means of electronic posting of the
HSA Agreements and certain HSA Materials through a private portal on Employer's internal
website and enable acceptance of HSA Agreements by electronic means or by hard copy as
determined by the Employer. FTB is willing to permit this process only if Employer agrees to
the terms and conditions of this Addendum.
1. Requirements. Employer agrees to (a) post the HSA Agreements and HSA Materials on
a secure, private portal, accessible only by Employees through industry standard credential
requirements (the "Portal") and in the same form as provided to Employer by FTB and to
promptly post updates as requested by FTB; (b) provide functionality through the Portal for
employees to print the HSA Agreements and HSA Materials, and the means to request paper
copies from Employer at no expense to Employee; (c) provide a clear, understandable and
generally accepted means with proper disclosures for Employee to electronically or manually
sign and accept the HSA Agreements and acknowledge receipt of HSA Materials so that
electronic acceptance and signature, or manual acceptance and signature if that process is
applied, is fully and legally binding on the Employee; and (d) provide to FTB an electronic file
that reliably reports acceptance by Employees who have properly received, acknowledged and
electronically or manually signed the HSA Agreements indicating whether electronic or manual
signatures were obtained and are on file for each HSA Agreement signed by each Employee (all
of the foregoing, from clauses (a) through (d) above referred to as the "Requirements").
Employer agrees that Employer shall not report to FTB any Employee as having accepted the
HSA Agreements who has not electronically signed the HSA Agreements in accordance with the
Requirements. Provided the Requirements are and continue to be met. FTB consents to the
posting of the HSA Agreements and HSA Materials through the Portal.
2. Employer's Representations. Employer hereby represents and warrants to FTB all of
the following:
(a) The method and manner of posting the HSA Agreements and HSA Materials and
obtaining Employee acceptance and electronic or manual signature complies with
Applicable Law and the Requirements, and results in the creation of a legal and binding
obligation of Employee under the HSA Agreements;
(b) Employer shall provide all eligible Employees with electronic disclosures of the
HSA Agreements and HSA Materials and;
(c) Each eligible Employee submitted to FTB via electronic file has accepted the
HSA Agreements and requested an HSA to be set up and has accepted and executed the
HSA Agreements requiring signature via the valid and binding electronic or manual
signature of the Employee.
3. Indemnification. For purposes of the indemnification of FTB under the Agreement, the
representations and warranties and covenants in this Addendum are considered part of the
Agreement, Employer's indemnification obligations under Section 10 of the Agreement extend to
(i) any negligent act or omission or willful misconduct by Employer, its affiliates,
representatives, contractors or agents (collectively, "Employer Parties") arising out of, or relating
to, the subject matter of this Addendum; (ii) any failure to comply with Applicable Law or the
Requirements by Employer or any Employer Parties with regard to the subject matter of this
Addendum; and (iii) any claim by any Employee with respect to the Portal, the manner or
method of acceptance of the HSA Agreements or that Employee did not accept the HSA
Agreements.
4. Records and Audits. For avoidance of doubt, the audit and other rights of FTB under
Section 14 of the Agreement shall apply to the activities contemplated by this Addendum and
without limiting the generality of the foregoing, Employer agrees to provide FTB with full
access to the Portal and all data pertaining to the Requirements and to the Employer's
representations in Section 2 above, Employer's records with respect to Employee interaction and
acceptance through the Portal and other matters and processes contemplated by this Addendum.
5. Termination. This Addendum shall terminate concurrently with termination of the
Agreement. This Addendum may be terminated by FTB upon thirty (30) days' notice to
Employer or upon notice in any case the Requirements are not met or the Addendum is otherwise
breached.
IN WITNESS WHEREOF, this Addendum has been executed and delivered by the parties hereto
as of the date executed below.
Effective Date:
FIFTH THIRD BANK EMPLOYER: E CITY OF ELGIN
By: i�2'G�r,� By:
Tile: Vice President Title:
[Second FTB Officer
By: Address: 150 Dexter Court
Elgin, lllinois 60120
Title: Vice President
Address: 401 South 4th Street
Louisville, KY 40202
FAL.egal Dept\Agreement\Fifth Third HSA Services Agr-Addendum-redlined-10-27-17.docx