HomeMy WebLinkAboutHRA Exhibit A EXHIBIT A
ANNUAL EMPLOYER CERTIFICATION REGARDING
HRA INTEGRATION WITH A QUALIFIED GROUP PLAN
The undersigned, a duly authorized officer of the Employer named below, hereby certifies the following
on behalf of such Employer:
(a) The Employer has previously adopted and made contributions into the Voluntary
Employees' Beneficiary Association Standard Health Care Reimbursement Plan For
Public Employees in the Northwest(also referred to as the"HRA VEBA Standard HRA
Plan")offered by the Voluntary Employees' Beneficiary Association Trust for Public
Employees in the Northwest(as the same may be amended or restated from time to time,
the "Trust")
(b) The Employer will make contributions into the HRA VEBA Standard HRA Plan only on
behalf of participants who are enrolled in the Employer's group health plan or another
Qualified Group Health Plan that provides Minimum Value(as described in"What is a
Qualified Group Health Plan?" available through the Plan's employer web portal) ; and
(c) To the extent Employer makes contributions into the HRA VEBA Standard HRA Plan on
behalf of any participants,the Employer will, at least annually, either(i)confirm that
such participants are enrolled in the Employer's group health plan or(ii)require such
participants to certify to the Employer that they are enrolled in a Qualified Group Health
Plan for the applicable HRA Plan year; and
(d) The Employer will use its best efforts to assist the Plan and Trust to correct or reverse
any contributions made into the HRA VEBA Standard HRA Plan that are not permitted
under the Standard HRA Plan document.
IN WITNESS WHEREOF,the Employer has caused this Annual Certification to be executed and
delivered, as evidenced by the signature below of its authorized officer.
Employer
Name: JJ
Name: OC_ Lo (7//l ( ,P Y'Ct CSu
By: (�fil',�g 6/eL44 T )
Authorized signature ti Printed name v
e/v. / bc.44 4_ -e71 09/28/15
Title './ V Date
(05-15)