Self-Insured Medical Reimbursement Plan

The Board of Directors has determined that it is in the best interests of  ________________________ to reimburse all eligible employees for expenses incurred by themselves and their dependents for medical care expenses that are not covered by health or accident insurance, subject to specific exceptions as defined by the Board. With the intention that the benefits payable under this plan shall be excluded from the employees’ gross income under Internal Revenue Code Section 105, it was decided:

Following are the eligibility requirements for participation in the medical reimbursement plan:

The Corporation shall reimburse any eligible employee no more than $ ___________ in any fiscal year for medical expenses.  Reimbursement under this plan shall only be made by the Corporation to the extent that such reimbursement or payment is not provided under a medical, health or other type of insurance policy, whether owned by the Corporation or another person or entity, or under any health or accident wage continuation plan.  If there is such an insurance policy or wage continuation plan in effect, the corporation shall be relieved of liability for reimbursement to the extent of coverage under such policy or wage continuation plan.  Any eligible employee who wishes to receive benefits under this plan shall submit to the Secretary of the Corporation, at least monthly, all bills for medical care for verification by the corporation prior to payment.  If the employee fails to supply such medical bills in a timely manner, the Corporation may, at its option, decide not to pay the bills in question.  This plan may be discontinued at any time by vote of the Board of Directors provided that the Corporation shall be obliged to pay any qualifying medical bills for services provided to an employee prior to the date of discontinuation of the plan.

__________________ shall determine and resolve questions regarding coverage under this plan, except that reimbursement claimed by this officer shall be administered by ____________________.

Date: _________________________