Fill and Sign the Corporate Establishing Form

Corporate Resolution Establishing a Self-insured Medical Payment Plan for Key Employees Whereas, _________________________________ (Name of Company) desires to pay or reimburse, directly or indirectly, certain medical and dental expenses of the certain employees of the Company (hereinafter set forth) during their employment with the Company as well as and certain medical and dental expenses of the spouse and dependents (as defined in Section 152 of the Internal Revenue Code) of each such employee; and Whereas, those employees referred to above are identified as follows: (Identify each employee) __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ __________________________________________________________________________; and Whereas, the medical and dental expenses to be so paid or reimbursed shall be those for which the employee, spouse or dependent is not compensated by insurance or otherwise, which are treated as medical expenses under Section 213 of the Internal Revenue Code and Treasury Regulations under that section, except that the amount of such expenses so paid or reimbursed to any employee shall not exceed $______________ in any calendar year; Now, therefore, the Directors of the Company do hereby adopt the following resolutions by unanimous vote: Resolved, that the above described plan for paying or reimbursing such medical and dental expenses be and now is adopted to become effective as of _________________________ ( date, but not retroactive) ; Resolved, that the Company at its discretion may directly pay any of the above medical and dental expenses instead of providing reimbursement for them, and may require as a condition of reimbursement that any employee seeking reimbursement furnish to the Company all bills for which reimbursement is sought; Resolved, that a copy of this resolution be given by (e.g., any corporate officer) __________________________________________ or his/her designee, to each employee named above, which that employee is to read, sign, date and promptly return for retention in the personnel file of that employee; Resolved, that the officers of the Company shall execute this resolution by all necessary and proper means. These resolutions were adopted by the Directors of the Corporation at a special meeting held on the ______day of ____________________, 20_____ . __________________________ Secretary Attest: ____________________________ ____________________________ Name and Office in Corporation