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* • •-- <br /> BASIC PLAN DOCUMENT <br /> ADOPTION AGREEMENT <br /> FOR <br /> CITY OF RANCHO PALOS VERDES <br /> This is the Adoption Agreement referred to in the Basic Plan Document ("Basic Plan Document"). <br /> This Adoption Agreement plus the Basic Plan Document, as amended from time to time, constitutes the <br /> Plan for the Adopting Employer. <br /> ADOPTING EMPLOYER INFORMATION: <br /> Employer Name: City of Rancho Palos Verdes <br /> Address: 30940 Hawthorne Blvd <br /> City, State Zip: Rancho Palos Verdes,CA 90275 <br /> Phone/Fax Number: 310-544-5204 <br /> Contact Person: Name: Eric Mausser <br /> Title: Human Resources Manager <br /> Address: 30940 Hawthorne Blvd <br /> City, State Zip Rancho Palos Verdes, CA 90275 <br /> Phone/Fax No.: 310-544-5204 <br /> Email Address: ericm@rpv.com <br /> Addendum(s)Attached: ❑Yes El No <br /> Note: Any addendum attached should be labeled as an"Addendum to the Adoption Agreement" <br /> and indude a reference to the name of the Plan. <br /> ARTICLE I: INTRODUCTION <br /> 1.1 Original effective date: January 1, 2010 <br /> (month,day,year) <br /> Effective date of amendment/restatement: January 1, 2010 <br /> (month,day,year) <br /> 1.6(a) Coverage options available under the Plan include: <br /> ® Full Scope Option. <br /> ❑ Limited Scope Option. <br /> ❑ Suspended Account Option. <br /> LI Other: <br /> 1.6(a)(ii) Limited Scope Option is: <br /> ® N/A <br /> LI Available only for Participants enrolled in the Adopting Employer's high deductible <br /> health plan on an automatic basis. <br /> ❑ Available for all Participants on an elective basis. <br /> O Available for all Participants on an automatic basis for Participants enrolled in the <br /> Adopting Employer's high deductible health plan and on an elective basis for other <br /> Participants. <br /> ©Hitesman&Associates,PA 2008 Page 1 <br /> Basic Plan Adoption Agreement <br />