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2010-94 InfiniSource Cobra Service Agreement
i N F I N I S O U R E SERVICE AGRE EME N T ftcrim l: GE-NERALTERMS & CONDITIoNs aF TnEAGRE mENT inpmsource Inc, ('7niinkwee") Owns mad oncrater v service eolporutim designed !a tied st employers with vanole ndmimslriuivc acrvlt related to ¢l mein bone plaits ("6asseft Pldn(s�"}, liasrsaa p and rtmintNncd b5' Employer (ms idemilled In Seedtm 3) for lire bcncfil of eligible rmphoyces and their eligible dependnnls covered uru'er ate Pion ("Covered individuals") Such. services melude, but are not limaw to. Ilse follarvrns. I Cbmpllanee will the Cbnsal4ded Onmibus 9udgei Reecimili Pion Act or i9115 ("COBRA'] 3 COBRA Premium Collection l:ervice 3 Caepliarmwitheartain.aspen:l;;ofThe tietdthlnsurallmForlobilityandAcaouninbilnyAct at19%JMIPAAPortability Admtnirintion) 4. Fnnsc ilenefi Plan.Adminstrnlian (lice t h wsftr Dependent Can Flexible Spending Accounts (FSAS)) (health Reimtsun ment Arrangements (HRAs)) and (Tronapti film Rat intsumemc it platy) 5 Premium Doing swim G Healih Sdvusgs.Ae Gourd (HSA.) Administration Service 7 Enrollment Lad EligibilityienijarwconsaiidolcdBolism.Service lotinsounce roll only provide Ina services apeeifieollyset forth to this Agreement dud chosen by Employer in the trees and Cbnssdemtion App pKL (Section2) oitoched to mad incorporated in dum x Agreement in consideration of Use utu+d promises sal rarilh herein, .t at gored py and between 1flGmsource wtd ussiploW (tic "panics ) ds fallmas A. COMaIENCpJ IM Or AGREDIR qs An MAi7aM This Agreement simll eommmime on the servwa effective date assigned b} InFinisource (tie "Effective Dale"), and d shall conlhuse wail terminated in negardsinec wish this Agrft meat. The Appendices micarpgmted Into Bad mpdo n part of ibti Agreement may helve d later affective dole. iL BCOP.9OFACNM174'i';RMArioMSblpor +ARTIgS This Agreement sets forth certain rights and obligations. of Employer and In;inisatucc, oral tits tins of this A(ireement shall apply loony assigner or successor of Employer aortae ]nftusoiace The isortlas intend that this Agreement will cmdblisir an indcpendml contractor relationship. infmmmce a no. an ur employee of Employer {for purposes ofcstablishing Pdricipal-Agent relotiorrsiupa}, and the employees orEmployer era not craned to ang of the benefits of ampayment granted by Infmisource Id ill ohtn erapplay�s It S tridcrstood that 1Rfhnaaace IS free to )rcrlbnn similarservlces for Bluer aroployers alpha lhm Agreement is cllix Ne .Emmp{rloyer is sokly rrsiornsible itirestablishment and operation ofibe ScneSt Nor* for tvhMi infinisotme providaa relotca services in iteeotdanca with thie Agrecmeal Employer has sale discretionary authonty and responstbllity far consttumg and interpreting the pmvisiohu arthe Bereft Plomt, and deciding all questions of fact arising. underihe Platte. H i5 Ettplta?ylct q sale respoimbtRy and duty to ensure cor(nPhnnee wdihh all apphtrible laws sail regulations, and 1pfimsaurcc's.provism ll of acrvkes under this Agreement does not rclicw Employer artim abligatiaa. Infrnisource a responsible for provsdmgservices shot comply wish dpocable law and wilulatians and that awn Cnnplovers with log obligations tinder surfs Benefit plans to the .extent set forth immim Subject la lnfmtsaurce's tvVisasilnliaes under subommthon O. 'Eimpleyer ddderamnds first it is Employer's respornibtity to fay any fee or penalty armed by Ilia Interriol (revenue Service, tie Depralment of Labor, or other stale or reJerul raguligmy ingency Employer acknowledge;, that Inftnsi mice is not an accounting or law Fire, and no services provtdcd ay lnfrn(murcc a. occordanre with this Agreement will be construed by Emploveras fix or legal advice its a result of providimg.such sarvica. All duties performed by hirinisaurce will be non dimmiionwy in nature and will be performed in eeeardiame with the terns arthe Benefit Plots established by Employer and Infimsou tc'R standard operwimgpmcedissm Infintsourcve Ism no discretionary wmhonty welt respect to interpraung the terms of the Benefit Plops_ C Flin It. consideration orihe pwninn ofserv)ce.- by Inihoworce hcmunder, Employer agmu to itinke payments in the ismounls 4speciflcd in the Pon Beetling hatein. Fallum in Pit g tars ley the due dale (Including any grace paned) may result In tie unposiiiai. of interest and penhsllin tatd/or Iegnitlptsnn ofihe Agrccmt rst Inilnisourca may Ehamgc the fees roe nay reason a tie 6rgianing of each 12-month pixiad begianng with the Eifeclivc Dtde provide4 ilia Aotroa al such clarrgps is provided at ieasl 3(I days bare the liegrnnmg ofatich 12-meet. prrvod. In additimr, Infinrsaoee rely tiwlse the tees during any 12-month paned if eliimgcs to the Bencfil Plans nr ripiaable law laic made {agffidleys t►f ilia tensors) that amtcrmlly revise dIc sutpru ar scope or;hr services contampldted by lies Agrrxinent $well clenges swill he eilocttve na earlier Ihen 3t7lfays aAsv InfirnsBusoe provides anthem notice to F.mploycr B. AILMIQMAvo*i Employer hereby mithonxes hnfipisoirec to perform any and all acts and dccdanecessary to periotm the duties as set forts in this Agrectrens, Including but not limited to, enlietuhg the aerricas ar a thud ppelt to ossisl Infinieourm vni h its duties hereunder Suca ihird partials have agreed to confidentiality rogtorements cansislent well Infiltbairce'a reaptin ILIfies :miler This Ag cni InImisourta will mdemndy w d Isola Employer IsQlnless Ibr all direct manatary disawam of a campeasdiarsalute "is na from the Intentional and Wiggly negligent acts of the third parly relpled to services provided by the third nary in accordance with this sub�secitdn D WE . *Iuycr requests Infirnsame to ocr m a =m et that ni Inamistl et wrth.the terms of ibis Agtocmaah and/or opplicuble low, lnfimsoarca reserves the right Ia refuse Bach rinquesl .rod will comply atilt such regtic.t only to ire Bxlanl Employer mtt>;ossucl+ resiuest in wrung L. INFORMATION FAOat EMrLOVER lofintwurce -mU establish various media& far trrrIPATI'MA Information In and. from Inftnisource. Employer mull use one of the mdhods aslabhahed b, Infmssource. tEmpli err uwilll iiluatsh n the u a In�fiinndin � tnaetrr agreed Infnisnoree to he since ry to mithsfy its rrsprnlaihilkics under tits Agmement Such tafamhadon will be provided g by limplayer and lhftnnalrse Employer undcrrlcads ;bmi laliniscur= cmniot dccuraWly perform tls dt:,",rs under Ina Agreemcnr. willsoul accuntc and taaely rnfmmotion and that Infinisource shaft have no liability to Employer or any Covered Individual n a care quence of mncrurole oridfor untimely mionnaLlo" provided to Inimisaures: by Employer, in destgnec, or another cmistmg or former service provider Innmsonree will have no obligation Ia credo Employer far any elitism expe"M or adrointstadve fags inemied or pond is Infiniaooreo m a eonsequemec of lnfinssaurce receiving tnpcerimle yr antimely inrormplion Cm oyei ,tgreaa to pay InfinMM-10 Sbhthdmrd hourly rate sat lortlt to the fans and Ctim►iticalia,r Appendix, r1 any, far.aty corrections riot must be made m .+ result oF9ueT. bmccurolc or ustimsly infortra4on_ Iniinisoims twill assume tut nil such mfarmattan provided to 1ni"inisusirce by Employer, ib dcMijace or EIPMbEly existing ar lomlerprovidriscomc andrsr its duty to question Qre comptelcrim or accuraity.orsuch talc matron, Employye�r will anlbrmntiOn and/or repels lxavided by ]nfiniaaosee inohdathewsdtrigAgreement its soon as possible after Employer Iris received such informetion, and will nolifylnfimsource of any coma m ntrch Inlommtials an � mporls na Sean its possible after ins rat icw. F. CONFIDEN'f1AL ANIIVI$L7.as= All f lions ration, whether printed, written or and. in arswcr to an inquiry or volunindly furnished by Employer or its agents or crnplayecx to hirinisesirce. sladl be held in confidence by Inlimaoutce and used and disclosed solely far Oc purposes at fulfillment. of hue lestns of lhis Agreement Employer oral infasisuuree each d4nowledge that its a "Mid[ of entering into this Allamisiont, each pmry bps, and will condmrc to reveal and disclose to the of cr, inroramtion t is prapnoWiy and/or corindenuol to such pony. Employer and Infimymax ree agthat each party will (a) keep such proRRnetdry nndlor confifiM al infarmmmn of ate other party to slrici confidence: (4) nor disclose confidential Information of Inc other party to any Thud polies or to any of its employers not a wing a legitimate need to know such Inldnhtottan; hhixi (c)will not use Lonfideniml inlbmin or ar drat Usher oi+rry far any putpase nal directly related 113 and necessary far the parmumni:e of is abllgduans under the Agmencnt (unins required to do ao by a awe ofoon.palenl jurrsdicnan or a regulntoty body laving authority m rcqure such dischnspre). Information revealed or dtsctosad b a party for any purpose net directly adored to and necessary for the performance of such pa rty'i obligations under tiste Agreement shall col be considered confidentio infanmdon far h�urposcs heroor (a) it. when, and Id the extent rah infssinnl.an is or becmnts annually available to the aubhc wmhadt Ice fault nr hegiipanca of the party reeeivmg ar disd�me the Wranndhap; or (b) if the tmrerneled Ise of sic h information by the party receiving or dgicWtng the t ilbrnulum has been exprimily authruind in writing an, m advance by an eulhariaed repiesmtative of the usher party For p. of this Sections, confidential informmnor is tray mfonmtion In written, barmen-riasdabic, machirse�reWrible, or eleetrnnically igmrded lbrin (and idenlded as cored andlorpropreiary ar wants armisiodr import) said oriormatan disclosed or dly in Mmiculion with this Agreement and identified as confidential imdhhr Proprietary (Of Words of similar uporth and ProLntmh policies, practiceut. procodores, files, reeord4 and wriespurtdence croscemfng thin pnrsics' respective Imioesses or finances -nic lerms.and conditions related to opnE-tdw+hsdity so qas Agrecnlen+ stall survive the teraiawlnan of tMs Agreement Employcragees that it 9ha11 not disclose to any other porgy, nor+hull Employer Inc for its otvn banafit, the details 'a wnuan evidence nfserviees provided by Infiniscurce berietaider winiaut afro expresx iuior written consent ofihfinrsuciree. Both pni tim agree to use and disclose lndividuallj ldcrihfable Health information, including Protected lieoith lrnfarmrtiUn, only to sel.fortn in the HIPAA Confidentiality Appendix Incorporated inla Ind made. 9 pan ort is ARmcrnga G. A»Drrs Lptdlilor,."i oyer (or as deshgrrolcd mgtid) miry perform no morn Ilhan pnc il) audit mf tie retards apceufieadly mlaled tin perforopince of du partite under gins Agrecmem rich sub"' reasoeror tyiant aplcasts ip tnses[iag F.mployrrta prrlbrin the audht Fact party aisn agrtixa Irt provide such acldiupnal mfantralion and n� arts, os tlhe odor petty will roasorwbly regarert H. Ei6remaxicADliirusriATmESER,,icLs Infinisourca forty provide certain elecuarrc adminktralhve services as Be: forth tp this Agreement. Infinfsource shell not bedeemm in delhlrlt of lhfs Agrmemem, nor hold rre�ionsible for say cessauan, interruption or delay in the peiibrmmnce of its obligaliaps to provide such sourer hereugdcrdue to causes beyond its remonable central, tacluding, out riot fimom to, hit" disaster, act of God: labor eontrovmrsy, evil dwitmbwn -c, diwupGan of iha public manors, ter urrgm. fret or armed tannic. rr rite in b�dityto obtain suAieient molenads at services required In the conduct Of Its business, including Internet access, or any honge in or the mdoptmn orally low, pdgmeut 1. PATA3KNIs To insmimusics Notwithstanding may provision hemio to the contrary, Smplpyeraifd Infiaistuuce imend and wne that any funds submittal by Emplaycr to Iniinsouree In sctarduce with (bus Agirrn.cnl arm 1"W ffam Employer's Sumai assets raid in no way include any employee coot t R310. Employer further wastants .md repreams That Such payments ram not made to Infiniaarrrce from a separate furxl; aceoury or trust bearing tie name of a Benefit Plan or then of uny Covered Individuals thamoi. Employer agrceg tiiatany oast requircments,lo the exiem applfcoble_ are the sole iesponsibtiityof Emplayer lnfrtusource may drpmft any amounts received Pram Employer andlar directly Dom individuA, cokerod under a Benefit Plan far porlwsca or paying Beaefil Claims or Inherit pion premiums to a general tusladwl ntcotmt maintained by Infmtsource on liehair of nls employer clients Any interest tuned ant res7axt la funds in the cumuctul account is retained ay infurtsource tie an admitUlWtIve fee in addition to to fees sci forth In iha Pecs section. In addttimn, any fees dire and, mynbfe to inTnisporee in oecanlsnce wrUh this Agmincia may be withdrawn from ouch account in The event that Employer has -faded to timely laid complefcly pay aregmrcid lea or I otherwise. aBmed to ply rim parties J. BONDING To the extent required by applimWe law, Infinisaace %viol Imitation a fidelity bond covering all Infiniworce's employees whu handle Plan faulh in accord ince with lbe terms aI'dus Agreement. This bond covers the 4amt1ing ofPlaa Funds from dishonesty, fhefl, Ibrgery oralleratson, and unexplattrerl aaappearance. K Cua%aIaNICATtaxs All tommunicafions provided Rw harem bcwxcn the panite shall he trot by t.anfnned fncsimilc, by gumnmieed.snrrmighl until, with Iaicing copabrlify; by rrSf clogs United States mat, with postage prepaid; or by a-ruril addrimod to the other party at 03eu "eeiive pddwAos as set forth harem. All eommunrpaions 6etucdn the parties arc deemed provided when cent except as atherwaic set faith in this Agreement Employer ngrees that Infritsouree may Communicate confidential, protected, privileged or ollienviic-mulove Information to Employer lhrotigh a named contact designated by Empluyar ("Gusignaied person") and apecif Bally agrect to fncieomily Itirm sinuce and hold it harmdm5 for any such darrulan or costs arising iiaa, communuzinn to such �+�nirkd Perron attempted via facsimile, mail, telephmu, c-um,if or any other media to flit extent that Infmisouree dui art 5mlwln its froward arcane in sending the tnibrmaiion L. ENTtREAGRF.EatOT This instrument (including documents speciridWly tntorpornted inlo and mode a part of Ibis Agreement by rarcrence)embodia die w#halc agreement of ttic parties There are na prooiracs, senor, t0,111WO s or abhgalow athw-r limn lima contained heram, wed this Agreement slmll supersede all previous communications, rc mall nr agreements, richer verbal or wnfirn: between the parties herein- Failure by Employer or 1nfinmouace to insist upon strict perrormance of airy prevision o tf i s A cment will aw modify such provision, render it unendbremble, or mauve any sunscnuani breach Thu Agreement shaft be construed tinder the laws of tie State of hdrehatari. if any part section, unuse. mrl,rovision or this Agreement shall be field invahn or untrifineeable by miy court of eomprdsA juradfcuon, sucitholding shall rat invaiidnfe ar render unenforceable &W Other part, section, clause, or provision thereof, 6t- AMENOEuw&,l�'An7naAm#AoDiFlcAnoNs Tills aWmalical. maybe amended only by written rgcni of the duly adwrizcd offidols of Employer and hifinas ismaee tMill. Otherwise set farts herein In eddititm, any failure by lnfin slource iv anrorce aright provided o• in Ibis Agreement limp not be considered a waiver of dial right undess expressly scf forth ah such in writing, N. Assimarm Neither party can assign ibisAgrccoent without prior ivritlen concord from the other party 0. INDEatNr puTiohANDLIAntuiv 1. lnfintsoome will exercise the some neamnable Core and due diligence in performing its obligations under t k Agreement that a prudent administrator in the some industry would camise (heron ancr, the "Slanoard of Care") It %]pill not be a breach or the Standard of Coro at laril, hercm tr lnfmur•,urec acts in mrardance with Employe'S tivriftcu instmetiona 3_ Exec% as otherwise provided is this Agreement. Iniinimurce will Wrinniry and hold Employer, its officers and empfaynes harmless against all direct monetary damages of a coe,pensatdry nature to arc exlcut .mph daitmges arc remmmhly meCrfeinmblc oat only to the cetera that such dnmagcs arc Itne dins t and pr7�pil tac insult nrdnfinisiirce's breath of the 5laadard of Lisresei Righ herein 3 Emoloagrcee io irulcahfniry and Imdd Iniinisaacc, its o(Ifcer;, and Cmplayeee harmless Cram and againal ell deter moraeuhry darhmges of O carnpcasoiary nnlureDori with any action, suit, mlmmusltaGve proceeding ar setticmturt rotated to the Bonalit plraa ter uiihidh tnlmfsatmec prcvidca admmistmfion astI-mr a to Employer to the extent sudh damages ansrng from or rdalel io acrvieea provided imdertbts Agreemem ore not the tired and prottmate insult of Irilina irz ree s bntitb of the al aidard oT Cars oat fault harem 4. Undcr rW circumstance will either party be liable to the other inn breach ofconitud claim for any incidental, eonsapfetfal and/or punitive damages, P DE FM PLAN CLAIMS lnfinnou ca does not insure or um[en%Tte the Btricdit Plan hoadiity ortmployer and is not financially responsible for the clamp, and/or espdurs incident to the Benefit Pions. infnnisource has no dolly or obligation to defend any legal option or proceeding bro4hl to recover b=111W under the Ileneflt Bobs. however, lnfmsmuce will nmvide to Employer and/or Employer's IeVI courtsel, upon request and subject to day limitations described in the; Agreement, any documentation is tafrnigource e possrssion that may telaic to such. claim for benefits and/or cxpepses. Q. nUMINAMON fit alamEEiHEril Ether party may terminate all or -part of iiup Agreement for any reason effective no carder Own 30 days utter ti%muen nouce as provided in the other parts This Agreement Will automatically terminate on the earliest arthe following dates I Tire dale thaf all Barlett plans fin which feinted services are provided under this Agreement have been terminated. 2 Ir the reason for Walf"ulfon Is the lhdure by Employer to pay a fee by the dur: dole f including ualy gmec period), laralltrttron Of thus Agreement trill he retroactively erfettive ae of die lost day of the period far wlucn a Fee was property made in ;iccoroaricc anon thu, Agrrmnnen4 cwxm as tohexwac provided in tinting by Infnisourec. 3. 'the date Can lips Agreement or all or file Benefit Plans rer which relied services we provided in aeco darim with this Agreement become in violation of applicable law. Termination of this Agreement shall not lermininc the rights or obligations or either party orift prior to tine effective date of such tepminalion. The indcaaiil} and canfidcataduy provisions arthis Agreement sling survive its termination. R. RECORDKMlxG Infinisource %rill muimairs tilt usual and engtomay books, recants and documents, including cleexrmnic records in Infrnisource's possessie., for the li�caer at die icon or this Afirccroent plus 30 days or eight years fohnwmg the dote the rcGard was created or mcclvw by Infinhource. During Link period, Employer has fire right oreonurnfmg access to lheve documents, and assuclh infinisaarm, %mill deliver coptcs craft such boobs, records and documeaus to its possession to Employer or its designee as swoon as possilde but no later than 30 days after Employer has provided u written request for such docanerns Employer shell be tequaed to pay Ingntso rceN reasmhable charges for tionspariation or dupheagan crouch records. 'W1 v-zwr 3 SEcnoN 2: FEEs AND CoNswsRATIDM APPElmx - Fees dire vt*k agreement unless othennise noted Employer shaft pay as compensation to Intinisource, ror its perramumm us bercin desrn'hed ror the services indicated, said sum itemized and payabk as rolluws: COBRA Services Eimployer Legal Name: C J 4 If C le r M o n I jUldell an Items to be Covered by this Agreement: COBRA Notice Administration (Service Appendix attached), Initials- C.lk7'� Date: � �jl Zo � D Premium Collection (PC), Initials: Included Number of Insured Employees: iLo Number of Reporting Loceiiors: I_ State Required NotirkWons (Please check if applicablek ❑ CA Locatiou(s) or Employees ❑ Sponsor any group health insurance or HMO contract written in the State of Ilfin6b Information and Fee SnmmaEM FeeTotal Onetime Nan -Refundable Setup Fee Annual Fee or Per Insured, Per Month Fee S * per insured emp loyee pinyee x _ of insured empluyees x 12. Premium Collection Non -Refundable Annual Fee IS * per company account) S Dne With Agreement. S HIPAA Portability Service (HIPAA Certificates of Credhabie Coversp HIPAA Portability Service Fee S. 0 per Insured employee, per month or an annual administrative minimum ersum per company account. Fees must be submitted with the agreement. Must have Premium Collection Service. Initials- S Total Due With Agreement: S Due IJnan Recdat of Invoice: Qualifying Events occurring prior to service effective date processed by Infrdsource will be $25 per event. For PC So -vice Only: Takeover Fee - * each Plan Setups over 5 - Annual Fee of,S50 each ,pedal. Notes: *Anted Croup Insurance Services. lure shall pay to IaSaboarea all Administralkv Service Fees *tired by ERIPA in the event areamcellathon, the Employer may submit a written request for a r•ermd of the balance of ifs annual ree(s). Refunds alum he Nulm Requests far extraneous scrviem such as arnomined programming or mponina, may be made in writing by Employer. Upon barmisnrrcc apprmai or such request, a pmgrunming ice of S l?S.Oo per boor coif i apply. I Infinlan me lbe Only- AOIS-FL Agent Number: TS Aecoaat ldo_ Service ER Dole. aw TIUM SEMON 3: EMPLOYER ENFORMATION AND SIGNATURE PAGE: I This agmment m hmby mode behvm fofiuhmw a md: & 9e ()Af 1— / t3utare&[,�twure (Ctia�TtsoaFltrrrrrvlietaw) EntityTypc: ar Ev6 yer C] Pie Admhigutivr Az- 3XI"211 Ad&= Chy she ZIP T Number Fax llrmaber Nataroa<Baaieami CamperyPieafdcN-PfaeaCPtint Llomperp�Cmrtact-Pka$PrisP CbdWbMdAddrtu © Chu* here iramud is de same farall ow*u pkr J3,rLL � E Yl d IEC61Mtt Electrosf ftwent Card Contact (IrdiAtcrett) Mpksl a APIPC'M, Ftnrge Hedetit Comae[ (ifdfferent) pfr�_r• 18C WAA Cmffdentiudily Contact (Prdirfereot) l , Jeh Fkf DGC-Vn! Po nium WingConleet (ifailreenej Co getion contact (irdiffamt) �e �l rm�tr�lAthl�aa(araii�retq GV'G E6e�ordcPYgaeeal 4tlyd t:brrCffCl rrMod Address ( rffmarrt) inpid Fnfp Bcoi& Contact BUM Addreu (ffdiif =q � •r "•vr FAA ConfideMmlily Conn GAdm1 rldreas (if different) rnarid%ong.. ele--mon n or &MAAddea (W&Bc m .1}r�1?e-r►�arlt'fl.v ■aa acwm Cmdael fo-lAa1 Addr=jd' iffer ) N i5 neceum ft'a Cenlfnn afi empbyoes Or F.eapioyw to whma ...•..r%mffm IM asay praride PM is fire performam:e of N drrdea as sd fadb is de HIPAA Conftderrtirdity AQteemem (if one b Mwh 4. Yma mmptetf un of ft DeskMed Persmrs Lbft indis" drat the fdlnv tg halivideels are mrdmrimi to carry out plan admitsgtrat[on fhnesioss that Emplayer perm a ror dw Phan (Le., dra eovaed Csdgk artd that hdhdwurce K artluarimd to dbc PHw to those zdividuds: x. �' ?gk-, H•A- I@ i-pGapxl 4. A Service Appendix is attnclW for each Service cbmu by Employer as evidenced by their mt[borimcd gaff uppmval initials next to the service Ctwscn fn Section P. Addhimml urvitu ardamd after L%wmcn ofthis nvewi at wiPl be iaokmkd in addondmr. IN WITNESS WIiMOF. Employer mud io(bdource bavo parsed this meant conshting orjSwdont: I.3, 3 and afl attached appendkes(s)] to be executed In Weirmaw by their undersigned oirteer, the scone being duly wNhor®ed to do sm Pia 91gjOcq4w#pgW 4ti7 in errsure timely processing ofthis agt:Carrnt filer sompleling all inrvrmatimmI reads. tuff"b w tka t]nty ACiiS-F% Agent74umbw TS AcCDW Ne.: Bervice Eff. Dow. sMnaAS DRW4 SOURCBSERVICEAGREEMENT FEDERALCOBRA,USERRA,STATECONTINUAtIONANIMRHIPAAFORTABi rrySERVICEAPPENDIx Empinycr hes independently concluded ihol one w rune of Its b —fit plats Ihd ecocide medical cote ("Hdaltb Plme;") me sdIbjCd m the provesioar of the (Ihmalidmed Omnlas BAW Reconciliation Ad of IM ("COBRA"), as a mognealiy amended, a uft the Ualfenaa) Servim Emplaymeol and Reemployount Ruts Act or 19% (USE MI w sobsequenOy, amended wirer the portahilily PwVhkw of Hue health lnstnmace Fmtabiili4r end Accoing"Ity Ad of 1996 ("1I1PAA") as sddae9ueriyaaaand:d. nmllbr Certain bewilit enntbno m rights ender date law, as subscqwco0y amended. CowgnerOy, Employer fs regimed to perfamd repair; acts m order to comply wilh these ]errs. Earployer Ins asked bt almanc a tomb* g with s>alefy ft EvpkgWx aWigatfaw under ono er more of these laws asset lbdth in the Feces and Cbmiderstion Appendix. This Service App m& deoori6es die rights and repmarbilfifes of kamb xem Cad Weyer wltb reseed to vorfrnrs radernl COBRA and/or usERRA outfar HR'AA p swity as lordote contatustion sec *cx prwhu by larsakowce with rt;ucl to die Heleb Plan:. bdf"..im= w71 else provide cunt and apdemd bdenution to g to compliorms with appilicabie Ismo4. fimhuft any cwr4p at madirrmliow he uncn aoagd' nquircaaenla, nolirenatien Imguage and related deps nectswy to od in ecowd with seid dung' or moffilk time. TlaaerwliSratim well be based Be inimismacds inerprdeflon as o cormil oatlbeaef`Ys mGoinhh atar of spplfcabte law and should ad be construed as tax or h 0 adwidx. Tide dghls and obl ipidom mWEwd below apply a* to Ode extent dhosen by Empmploryer as the Fem an draw. Appe d AAppondix is to afkada dote of doppendix ;� into made a part of tie eerie Agreement (the "Agearamat"). The cM=dm date of H6 ialiies of are Agp adGr fint dew my by � see 1 thas d9fiflid en Agmeem ibom Ins a wuniCt the s Service AgpdruCe and � � fbab � this Serrlee mein addition to AV e�cdx, the ASncaddrrd cmarols. NOTE. EmPoydrdm* choose am or more of lee foflowbg sarwim sets onto Fees mad emakkuhtion Appendix. A. COBRA AINIM11 FIVAI rd Sta[wtt7en Rispandbillft oftollobauree. fallo gR Js WBRd: iftr3* w mall didnbddle its slandord notica a tin fallm * midaatiws when: entice is regrdred by COBRA. Including Ibef. imalofit a wal Nottem. Inratitoorn aa71mod fo standard COBRA geaarol notice (" t'iudaral NWO") tO the last kttomt addm of e" eavatd cmplyR odit rdldad n quked by appllealtle law, the CNN or Ow covered depmdcat. lafthance ht net nspon ile for any lodge or addiifess mmb Ia theme! by E.mpioyer. Infnnswoge tall aaly p wdb a Cameral Halloo to geltniddmis who beemae cowad &flee aeedwive dale ortbis setrlee Appedix except m adow)m opted fo by Wmeem x Soeh CamW Notice will 6 distributed to covered omeed; ptoyiaWhe amend sPnISIII (ifeelfag plo1 A difreenl Claim) ns moons rensooddy pm ailde but no later flan 10 business days atkr r:ceiwfng the wWW iihnontiet from Employer or its dealtgddee I QwPAft Even EL%-dw Abxkr:, h1fledu t m will and im sudard COBRA election notice ("Ehrimn Nwice'l to the bet lnnam address or each Qualified Bermfludi dy entitled to ekd redual CORM whusnun i® wwnnp. faffinwmee a not n hlemmiba fur any dtaagm or addfliois shade by lsmp[oyer m the 1=kciion Malice lrnq Qnalif5od Bedefidmies rroide m tie smne mldre� hdfma tdmy sand a slag!: peCam Notice and from in acaordaace wide applicable law. An EkWon Malin will anly be not to Wiled Behmilchwies wimse Quelioing Evan auems otter dhr elreneive date or Orin Agreeaam, adcepi as otberwhe agneel to by Isliawma. The Election Notice will be sent to Qudfrwd BOCKisrlet ens mesa m anowuhly pdnsstldtc his no low damn 14 colsadw days after raeeiwiny, the r gWmd iofaanotion from Employer. its dedgmx. or where applfeable, fund the QudiGdd Ben111WI y. htfanlseaea will aim paltry QudWmd Bewrieiedes of their rkhts to an exicraion of CORM cowkssdion doves' ymn PVw w0ficalion tirom the Qnelfrmd Beasfo:iaty, Employer a Eagdoyer's dedW= or an event tlml will mstaA Bowe rag: under appUmhle Ian: hdudsource may rely an a cadfleafe from do respectlwe pm*s Out me Brea perhok g en exlensma mreave ege lug occurred. Such notice will be UN ns smn as dmsm o ft pow"h: but tot bW Ilan 14 eatender days duller neealpl of apace mfice Of such Creel from it Qualified BeocrnebM Emplayenm Employeesdc*=. K At W" of (marnlladdlVif InRaismec reedvcs notice from a Qualified BencrdCiarj; Ernfdoyd r ar Employer's dedgaee that a QutlUyndg Eveal has ammed or Be evert thin call extend COBRA coverage has o:errrdxl, od such Qualified Benerr Jury is ast d:ligilde far COBRA in achew4 me with rdsoo.1 maintained by Mlinhouree is fire now of perfvalag ft d u order Oda AFemcoL lnftnilource vdU and the rawind Mi m rambdlity Ndlocl as anon as potodble but m few that 14 caleadr days offer reviving andoe hoot such Qudifiw Bernet reoliat noisy, langdoya of Employer's dmsigmen mAbe Inn kaosmn trddten. Tate lhwemlebd7hy tdotbx will osdi:aee the rmasons far fdtdip'bi3ily. iv. Malce grEartf 7kmdaadm: lafmlmmee wall send m notice to the QmWed Betalciday that envaW h o terhahw d before eke end of We mashaum period ofexwataga ("WY Tetmimtimt Notice"). The Early Towunatien Nadw will be sent to the last knmum adilum orthe QwVrwd Benewlary. The Early Tandentiao Noft will be rent as scan m pmsate bet no inter lion n tenaeable amount ortime after COBRA Coverall: has ended dhdinho wce perWrms Premium Collection. IfBmplayw dual not saodr die Preadm Collowimn wrvice, then lnrdaBoorce will send the Early Tar lanflon Notice des soon m pee dole but am later time. ten I I - -days after receiving the mgaired bifbrnatlan barn Employer or its designee. (b•) Rapame to Prarldex. Infmimdoce will provide nu umw 10 ingndriee by proridaa anrllet beg== comko rejotding Coverage smug of Qoolifted Beneficiaries. AU respoaaes will be based solely an the imfarmdien pwvidel by Employer and maintained by Infmiso m in scaudhmcm with Otis Semee Appendix. (e.) Goverment Audits. Indbdsa har, or its ofyiew or desiphateed agent, sW alto provide records and dwmteatdfart for my immix held by do lemma) Rewcaae Scm-. of hmft by any PwanmOW agency or Inman, tegardfmg compliannce with COBRA by Employer w m to onW Emplttyw at meh hearing incvidmcingcmnplmisc with COBRA. (d.) Reporting. Infidwarce will send or make nvaiehk stadard verifrealion repeats Wag the COBRA notices sent an a perimac basis to Edoptayer (or ens daecicd by Employer in w kh%l (e.) LGERRA Complinam Wbwa Employer indicates that a Qdmiifying Emu ism nwh of Ilse covered employee's love of obsatoe ode USSRRA. Inrmimaree will include vablow in its Notices to addmn L SERRA. R:sponsbNhlmofEmpi w Employer is rmpm Nc fbr all COBRA adknisistradam not pod lath in A.l abort, ioeludt but wmt limited to due Mowing: (a.) Pollees Required by COBRA. Ewptoyer towel eepon all such Wafludion aeeaaay fbr aUtilamume to provide COBRA nadfiaed a h; for Emplmyar. Employer must tc wit infmmatton act to compicte the Oencul Notice assoan w passible after an i divMW beeomm coveed tut no leterOadn 75 days Brier Han eomaenCCm ont of aov®ge. Fmgdloycr dell report all COBRA Qadifybdg Events 10 Idlial am as won m par'ibie after the event mee= tun no beer Omn 30 days after die event, a cepi where the Qua lred Beneraimy fa ragohed to pm Wde notice ofa Qualifying Event. (b.) Meeiraaic Reparti ng in Indlabsur e. if Employer choom to repel cenein infaradmiaa to latitdsotsee wit Mactm is Data Trataer (EOT), then d nplayerwdll comply with Inrmisoame's standard EUrpradxdmm which mgWta telling of files before EDT becomes openeimml r b ado for p s"i ng aoceptable Clas for tmft berme EDT becomes vpeationel. Ono: 1xim&ocne m hex emlidaded testing infinisouree wUl natf�y Em�player (a) Verifiwllon, Employer is mgxwible far rmviewing all standard veriGeauan rgKm at" iQ A.l above and tepw trg oWdiscrmparncies pmmptly to hnrmisaace. Wuneea:e Use OrOyr At3i5-Fl. Agent Nnmd wr TS Account No.: Service Eft: bate: tea;.74MI B. RE'AA IMAM rrY AaainaMATtVEStutvtrC 1. RcsrpawlWidaa[lolhrisousce larmhomce will dmbft to hs smnderd nathxs m de followM situr=s vdretc mike b regrmed by MPAA, (a) BMA Cerdlinre or CredIMMe Covmge. Except >*= Employer has entered no m mnum opwinew wlh m iremaae s wirier fnr ptapoafs of slultug WAA reVa AUkf to the. 6waersoe rani x. Irdkn=m will pairide s Connate of CodkMe Cwaage C Cerdanotc*L n rege[red rider HIPAA, to acb C&mW iadhMW who louses covemge rmdcr dpe eppjwdge lkahh Pbas apart afflict rwm Employer blot corm hos hcm kummad (fibm appECalde). llm cent Lmo fa mft lass oradln cava my wm be sad us moo m poaad6le bW no bier then 14 celmdur by alter Irdirib u m's rcxsdpl of k bmudoa lorR err imeece will word the CaMicste required at ilm end of CUBRA eovwW vn'drhr is remmud& period of done ufkwCOBRA ends. iafa+wmee will aim sand die CatiGcde to a Cmwed fad(rdd W upon rrqueet as log m Our request is mode vrihin _q mends of ore don dual cwcssga was loo. kdW macc WE euwpkte the C mdfkW wills nece mry infiffmWim provided by Emplow and Irdbrmdion mairealnel and rdsleioted by hiffibomce in deeoaaeofperfwn tgservfmmdwg&SevhxAppendixoriftAdrertrmL (4} Offw HIPAA Notices In WdWNm, IRlirdsmuce will provide Emiployer % tlr a simple HIPAA Combined DWee (adrieh inchdas It Nance of Sp=d Enrdbmrd Rig'kxsr Eieurrol Notice of Prc-IbristinR Cowaimr Eubeam g43% McIfindon at Cavvage Form, erd Written lnrlructiwa far OW ing a Owiliede) oft iartivAW PM Notice. (s) Reparfmw, infummuee will scud or metre available dandwd re1, — Balsa the OuiFirades sca oa a periodic basis to Employer (or as directed by Employerfavdift). 3. HeilromMEdes of Employer Emplartr is responsible far all HIPAA paladality x&niffistrrlim not sd hats in 13.1 shore. offing but not Iumted to the falloaiug (a) KWuL Euq&wa will provide the HiPAA Cbmbbwd Notice and iodivided KM Nddhz� to the eadeot gpiirable rsWw do Heft phn(s) in aceard i ,; wfda MPAA rr*laFimm Typically, do HIPAA Caskined Nocke mud be provided to all rsows y d*We craployem and the lWiv" pCE Ndke mug be provided 10 on il&Mad wlm Avers prior ct 911111e ewKsade ally Employer delrmhm dw amount of eedkeble earerage and any r-E+M FM Pului MR90M is tiro MWDMM9 for inserting any HE"M wAbW Provided by farmimurce Into its PhD dociminob mad mrmmvy plea desrxiptim% m appl kwIsf a. (4) RUPMIIMS mayor wlu repwl >d1 srrrdc uc(wron iwr DOM= y for hdbdsuawce to MAW Cerisficotes for Emplorir or accordmRx with H1PAA rgerkdry is a fwa d a ppmved by rermhonace. In oddiliort, Empiaym Is resporoilfic far mliCyfst Wmbow= that active covo r has aided ror novas ad- shoo a QWirying Etnsu [Ipan ecgtarst by laruoi+aereq Employer is resp:aeeR�le psnidigg tirTr omae eN >tofasaalioa aw edravvbe nraiarainal by loiiramurce do is occesury to compbs>s the Ceetiftdo. (c.) Vammi aa, Emplayox is responsriric for ravxwft all swrAwd verification reports set fords in D.1 above cad mWwft any thump da prompdy to Infinhomm C MORADUMCrSUVIM 1. Rea<wailgilhs of Iagabraree (a) Sugh Nmi@enlsa. 111110katnee will provide Finrplogw with temple COBRA DoWlestiM ((imrral Natae; Sloctisn Ndua Nat Notiee of thurmilabrlfty) shot am requW by COBRA vvAh respect 10 its Heagit Plru. brfirshoweavill pal m Earploj*m s bddfConve+siM Ektetsims, ExpirwIM and Termination notices as soon as passibk oiler reedviaB ntreraadm barn Eraphryer neetraary io eamplrspe merit podrxs_ (ba Reps. fa6e(mume will send or meka avai o stedord verirowGar asporls listing doe COBRA srrricea (pray to era ended Art Ate native was generated by krrraisowce soft we; If FiROoycr uses paper adee, dense will an be mcladrd is Ilse vcAMcdrm repmfs) sent m a periodic bask n Employs (m m direcled by Employer In vwRfna (c.) Grverarowl Audits. lormisource, or its ollicer or du4pued ogao, shill aND provim ree wds mid documentation ear any main or beating by nay sairermmlal agency or bureau, mzrrding dance who COBRA by Cmplu�w so ar n owlet Employer or sack hearing in evidr u ft coWINm wilt COBRA. 2. Respee lbIllirrofEmployer Emp4w is uspmaihle for all COBRA admirmustim out ad forth is C.I abom btdwhas but ant Iiudted In dw fs®owbg; (e.) Nodom Employer will be uspmese'ide for genvating and moiing COBRA udifiodims (tumid Nothm Media Notice and Notice of Urmrai irility) in acrordem with COBRA rewdogms. (h.) Repordog. Bog I%- is rco pooskk fa providing all kfamadoa to fafirdomce aecessmy to caupkte Arc Conversion, E--xterrmn, ixpirntinrr, mod Termtr m notices. (c.) VerMullau. Employer is mspnnslble fbrtevkvdng all:aomilml veriliedim reports act fmdr in C.I above and repmlkg any discrepmeies promptly to fnfrabmrnen D, WAA Ptserwaa= Au uuosrtutTrvE SERvH=riN Cvruur>vrwu wnv COBRA lllR=r I. ResponsibMiioserblotsamm W Sun ple Sellfiestlon. Inlinitmuce vvill provide Hmpfoyer wide sample WAA Cesbfamses and Habra of Special Enrdbaertt Rights rut knitvidard PCE Noire >hd we nquked by HIPAA'e porn W by rides with respect to its HmM Plan in additimt. Inrmisomce will provide Snployer wiolt a sample MPAA CbalkW Notice. Under this set of &atvicCs, Iafnisaurec does not rran the onlices w Ckatirrcdes, except don CWHIeatea rowha COBRA coverage. IniinFsmace is not responsible fro any $aoges for additions mode to the mlka by lim0eyer. MI Arc loss (h.) Reporting. Wmissace.n'R sod or nuke available slurdad verifla doo mpmu Iktisg in COBRA trmicos (aNy to the extent am the M4M scut was gad by lniiaisource soRwora; VEugiaju use; paper saatple notion% those: vrll nil be mckded in die verificddm reports) sea on a park basis In SqAq3w (or w Owed by F.roldoyer in wrilingl. (c.) Grvern ent ARdhs. fafmmmm, or its of wu or de Volcd agerot, shell a1m provide terords and docmaenmtion for my huse or haft by any voymmuntal egarcy or h ormu. regarding eomplbmce whh COBRA by Employer an ae ea amist Employer at such leering in ev(derseing couq&nm with ?. RaspoudbiBtheofEmployer WOW is tespmnibie tar all HIPAA portebiifty oduslisk Won not sat forth in D.1 above. irrchuft lea cot liaised to olio followirt& (a) EmPloyet wall be mspoan'ltie for genaWng red morliag MPAA noitieetiRne sad Corriihstco ro tie exim appllenble raider the HpmUh Plan in necmdosce %M HIPAA resdoliona Typically. the HiPAA ConsWred Nod= rout be provided io di aeady d4ft nsrgdoy=% mad sic lad(vhhrl PCE Notice must he provided in an individtrl who dxm prior criAmbde eaarerW aft Employer dcmmdms the amount of eeditoble covemp cod any rmsoioisg PCE period. Fagdnyer Is dw ttspoasl6k for inserting any HiPAA vebiw provided by hd'otdsmrrcd Waits p1m dneuaents anti mrm ury plm drxripioms, s applicable. brfmisareo disc Oily. A S-FL Aaea Nmolxr: TS Accamt.Hm-' Servim Eft Date aa.T-2&n (lx) Employer is repondWe for reviawng all slmtdmd voriftaetfoo reports act fadh io D.1 am and T zqmdnSam!' disadpeoe[es promptly to Intnisouaee IL FWM11tetCOLUX MKSEFtYWM" 1. Rsppaa[lafhdaarres (a_) Prong Eteeddm mrodswce wr7l process the eiecdm fmmv sabmfued by QmoWwd Benefidwm in wwdanee wilt Vplimble lew (COBRA gad USBLILA) and l mpioyco, b" wlio m (b.) BWop Infiflimi a wt71 mtYy de QuMW Bewliiday of the amonmi due for the initial ptadwo, as delernbood by Employe, which will be cmW& ed doe 45 dlhs after the date due elution is made or such looser period per Employees inhodkM IaFmLumaee will provide QWirnd orHenficlory t fyft Me Qualified 6YBeneficiary dicoYeramount dowel Ib do betcAnd dwlam Mc•whick will be 30dw from do rust der pnymearts dew am err prior � dw etfoaivo drm orsbfa Sa+riee Appaidir, respmosibla for almkdddarr� rho premium poyaewru for day (c.) Pees I Processing loruAmuee wgl cenrsidar premiums (body seat if they are teaeirrd in du affees of InOdworse or posted by do applicable gram data as lined on the premium kwoicc. Prearinow collected by Winimueawill be depoiied iaw a eavtsdial book awaurd maianthud by lmro&m=as art forth in the Agteenacat. hr6n will send a Fattploycrall prey caNaaTed & ft a wM* bytbe 150,blebs" day mowkI tie cad oribe ttt0096 Minced by the 3-A atbffinistrmiva fee which bdbuisoace will Icerp w part of ds Ducal r&miastradw ha l dinf neuve WIN submit pttsnhe s to ggtoprmtc dtkd perifes ady aeon written irtwu dlon. fiw4 Employer. In addition. Iormimmove: wr7 rbm my bNcra! eearwd as such Canals chic field in ® Imfadm ace walom red rautodid account as an whomiskarve fee. Modiletuatt do above, prerniaas will not be cwwA led wish larml aarac s own ftudv. In the even drat a peen® paymem is txJgjW due to icmlEcimt fiesta ar tie Get tla Qmn&d BwrKWy lee slapped payer, atria psi VA be eon gad as a awr.ptrymnu. V bdinhw age kas oka* cart ft prerakga to do ftftcr betac fadlaisuuee beaerres wawa of the telexed pttyM90L Eerpiayw andl tI I 1 0 hrrohoutee the moomw of rho mjmkd paymud, well do Qeslirad Bmefieir.ry s period or wvcrage''ll be adjstcd accoiftly. NonvitiieB hanunoydinit to a* cornray, ha aiaamca vom cam= to pevdde this srsrvice for Qaohf• rural Benefwimies vAme CMRA period etch after I[ araeude so lutrrg w their U5k1ZRA period condom (d) Rojrm * htf mucc will provide standard waffico m reports ea a perioerw bluets w Iaopl w(oans eRaeeted by ftpkly r im writingj. �afEatpWyar (a) F.mptpper Do1id F.mpk3ya is rule far all t"q®RA praudaar mlkctfon ekAies oat tit rmlk absve� itr]auii�heu red limier! to rite faRoae6eg: DO pro d= Vocable. pn;mu,;n.amgma 6 well as any adder rdeted albmagoo that falkwotaee teems meeo awry (ell, doe dada6 err.) sad sty cloves go lie opprdde premiums at Icau 3o days prior to de dradw dap or Reds dmnge. (c.) Vaaeheiog. From tinic to thm Iwo Situations may aim ralaed to votwhaiog. First, Employer may, in its dksredew; daefde io make special o�gmwsrs tbrpreanius payatesus ea bdtalf�ptuus (ell., deduretitas ftaeaaovuaa,: payl5rcaod. Quallfiad Ilenefmiaietr nmy irradreetertdy nerd � payments to F�plgya or some odder iaacad orbtfiafamars, in din rose, on pubes ogee in am fallowing proeedI • sign a�pdole p � waryla Ci BRA t�uaods papaly toadrraml{ymrl payatera, cad will issue a ratr]ta Re tie 214 administrative fee dram W above. • EmpllayerAd pay to voucher for the 2% odEfolsmutive fee, wben kunie ct (d.) Verification, n EI dove attd repsrmrg any diswepmwies pmarpdy b lnfinfsoace. F. STATE CI N"lINUATIONADMINISMATTONSERVICES i_ Rapoasibiida of 1aRmismtrce. (a) NotkM liftiaoues will dis Towle standard mom del ectuoy With the sine (ova drat govern healer idNHn a epntinrmrimt, as act fmdt is ft Face and COMIRIualran Aammik (b.) Requawa to Providaa. isfmismoca grill provide re W000ns to inquiries by provides aadhar istatmes couirrs regarding coverage stews or Qunnrted Beuefieias. All responses will be lased solely on the infetaatimt prodded by ante aw Ind arintained by IMhdsoxce in occoni Ce wild rids Sevicc Appmdbn. (c.) Government AadNs. inrmisourdx, or its orfiear or desigramd qMd, shall den prurids raeords Ind dneauaetrtatiaa ra any audhl held by g tack Depmdmtl orlwo mcs. or Nuft by any gavmovenfor agency or bureau, muting wonomoce with Aare won admr laws by Elaploya to a in asisl F NAWJa at suck bracing in widowing compnase wih slave camiand" laws (d.) HepmthW kdkmL= will sand or make ova ddc amdud vcrilication mpats listing On state corainundon oalim sera an a pain* basis to EaWAW (pros dkocted by Err pkrr r in writirqj. (e.) Prdedara CaReetron Saslees: bufiaisornea will perform der fallowkw (1) Intmisflwre wit prsecss fee election forms anbmhled by Qualified Bewild Ties io accordance with appRembiz swe law and Eatpiores kntrunkma. 00 >lff bit, M11015alrac wnl adify lira Qualified Bmd'wi" of do; eamined due fu the h' *' W pranaium, Is determined by EW]oycr, %&kb will be eousidaed due in a coodsuer with laYmisosaws per, lafinisorace wit prarida due gtdalfiisd Banerciary wWn ittraiests tmdrybtg the QYalilied Owlickmyerr tic anoaed doe, liar due date and *wpm date. Inrmisautrcc wig ant be rmlionveldo for sdraintvtoring aloe protium paymads Ibr any paymmb doe ea or priarto die effective date Ord & Service AppmdbL (ii.) btrmiaaaes• will eoasidu PmMierou dmdysau if they ere received is the otiimr s of inraiva ce ar postmorW by do appridrte geaoc ride m 16fed oa the pernetara invoice. Preonluns eolleetad tiY �fiaismace win be deposited iraa a curipdial bmnk oexeraet mohrlsbeed by Ialnerdae e m set fords is the 1lgresnttad Wu m m will seed to EmplaywgM prardens raneeted doming a month by tbs 15th basins dey folevti ila pad of tee wwW6 reduced by dw 2%. Mkokbrtrative fee witch lariionmee wil keep os pert of its overall whothdAmtfve lea. Infinisource Will srnbutk.pnvrdurm to appropriafe ddrdpmties mdy ifGct M and apoaw ifto. rcgtng fteun Faop(oycr. In additfon. hdbdaouce wil retain eery watest termed on scab Buds vh1c held him pd3nimruce undoWned cudodid occount as an odtafa$dralive fee. Notwithstw ding litc above, preeaiuuas vn7i mot be eaauE�led wilt Imfiedsomee's awtt ftnndt. In tote erml flats a premium paynteud. is rejected due to ireulfieiemt fitady or the fat the Qualittcd Hcsafiefary has stopped payarat, such payment Will be taaarned tin a non payrmac If Ioriafsouvtx hsu elrmdy eau the prmtinco 10 the Employer brrom W aismues becomes uww artbe rajeeeed payment, Empt*w soon wbokrrse Iaf of mxce the mount arthe mjecusi psymrai, and the Qdaitsw Benerrrws paw ore tigbiity will be ndjwtedaccadmrgly. Reapoadblues of Employer. FanpktW fsvespuerible foroil odes gate coraiaadiaa odminisamtim noiset fw* oboes; nnektdng boltmt limited to the followkW fWfrahwM Use Coy.. Aals-FL Agent Number. 78 Amount Nil: Service: Eff. Doc Ski% I -ME (a) Notices Required by Sense Lax. Employer or its dose a must report all such bnforowdon 1 geerier�ry for hrGnisautie la provide notifications lbr Empk,yn Employer or its designee shall report all Quahryang Events to Infnisoureo as soon as ,tandile alter the event occurs but no later than 30 duys attetdre eveni. except where the Qusliitati Beooficiary is requrrod Pa provide notice afa Qualifying Event. INFINISIOURCESERVICE AGREEMFST INMISOURCE HIPAA CONFIDENTIALiTY APPFd4OIX This HtPAA Comfidcntnollty Appendix (Itcram otter Me "Appandhr") is entered into by and between Employer in its individual capacity and on behalf of its group health plan(s) (hemmmfter the "Phm(s)") and Inrmisource, in its capacity as bode ucrvice pmvidcr io ttta Pius and io I;mpiayer Ibis Appendix is Immiloomle d Into anti atrde a part of ilia Infinismirce Scivice Agreement (Inc "Aglowneot'1 entered late between Employer and InfiruAoauee This Appenddix is cii'ecuvo as dr 0te date net faith below and not necessaniy the ct'ledwe date of the AgmmmenL It is etreclive.utdil this Appendix is wamuwled as set forth bore or tine antis Agreement is tcrrituadw in accordance with aw terms or the Agreemeat. A. SctmsANUPtraros8 Generally. dais Apperwin %,mtended to comply with the prlvWY, seemly. and admaristativa simplification mWiraments set forth in 45 CFR Paris 160 and 164 (its. "7rrivacy/6ecurity, Rulee"), fasued pursuing to dra Health Insurtmee Pnrtoliifity and Aeamintability Act of I94ti, Public Law 104-191 ("FIIPAA") Tate psniet acknowiat)ge thRtlits Appendix is untended to serve the were pmptrset as it Business Associate Agmementab tlmt term a defined in the Pnvaey/Securky Rul a In al rcmnlf to this Appeadia, both Employer and Infuillsource ncknou4edge date die Plan and Employer arc separate ona distinct aatnfes and do inf llik itcc may perform services body on behnirorilm Plan sad aiso on behalf of ftplayer in its capacity an Platt Sponsor In iimsource it considered a "Business Asseciele" aatder dtc Privacy/8ecmity Rules only with restates to services n.perfarms on behalf of The Platt, ifmy, and -pro "AgcntafEmployar" Witt respect to perviceJ, tt pa*dm on behalf of Ftapfoyed/PIAn Sponsor. if any This Appeadu sets forth the responsibiidies of hafmisnumc ftr Its capaatly as a Business Arrocip% as rcquwW by 45 CFR 1164 304(e)(I3 (and is refused io by thin Approdat as Bvsirdw ,Associate when addressing its xesponsibrfihcs to The Flan) and in its capacity as Agent mfEmplsyer, C required by 45 CP% §164,504(i)(2Sfi)(H) (trait Is referred to by this Appendb, as"Apirt arEtppleyd' when addressing cis reapoitsibtntas to f mplayer Thib Appendut also sets tent ilia aospoaiabilidea of Eaiplayer with respect la eclinns chat af[ec1 InGnisourca's Irblwna►hilfty larder this Appendix_ Inimisourre is referred la as "Agaml of Ftmtploayer" In bath AppeadiK for ire sole pui(rosc of idciitifytrg the disuisclian fiottvcci; j(d �ulc >ss a soervtct pravrr to die Plan and as a service provider to Finphoycr Wlth ragatd 14 the k15e rail disclosure of htollG infmtnolion Tile iL1ie arlhC icier "IgCht' is nag iotendea to deCnc die Irgn! tcletiamhip'between EmployanuAl InCantswura D. Dta"Mrt' OM The terms used throughout this Appendix shelf have: the following mcnamp: J. "Designated Remit Set., will have the same m aning given to do term "designated record eel" n• 45 t"FR §164 501. 2. "Group Health Plan" or "Me wdl buvc tic some me"nmg as ft tam "group health plan" in 45 CFR ii 160.103. 3. "Individual" will have the some meaning as the term "individual" in 45 CPR $ l60.103 and will include a person who 4uolifien as a ponomt (epiesadattvc in accordance with 45 CPR § I fO Wg) 4. "Pdvary Rule" will mean der Slmidodb for Privacy ofindividually Warlif able Acalth Informoiioa at 45 CFR Part 160 and Part 164. SUbMU A And E. 5. "Protected Health Information" or * PH)" will have the some meaning rb the term'Pmteeted Health bnfotin ttion" in 45 CFR jlftl03, lindted tattle inro,tnadan created .or iteeived by Ausmrien Assotaala form or an beltair of the Plan Pail will not include iiiotrnatnon amatcd 4 Iniinkmaree m Agent of Employer 66. "Itstepresritallve" wall include Ausiattss Assacrate's managing membam (as applicable). tnrarcea, pencral partners ins applicabic) and rmoncud and legal wviu 7 "Required by Low"wall have the same incomes as the term "tequtred by low`. m43 CFR 1164.103. S. µSaerctar y" will mean the Seemiary of the Depalment of 1laidds and Human Services or Wier designee 9. "Security Incident" well hove tho some tneamng Lathe term "security melodcot in -4.4 CM 1164 304 ID "Security Rule" wilt mien the 8cearity Standards and implementation Specifications at 43 CM- Pad 160 and 164, 5ubpan C Rurott mu nimorSttsirtmAssoctArn I_ Swpe of Responsibilities All services partmined by lnfinisource in ticcardence with the Agreement other than those set tbrtdi in Sect;oa V2 lierein will be considered peribrmcd an beimit art m Plan and an subject to the provisions but ranh in this Section C 2. Confidentiality. At all tilnas. both during and alter the lerminadon of its relationship with the Plan for any reason, Business Associate rmo its Representatives wall not tax, disclose, or awe ouiem any aftne PHI m any mummer whatsnem. except at provided in Sectiom C 3 and CA of rbru Appendmt, and will hold and mofntam the PHI m confidence. D.usiness Associate will ensure that appropriate sefegttar¢e art; in plant, in prevent the use or disclosure arthe PHI otherwisc; lbam as Permitted by thisAgreement 3. Permitted uses and Ufaclwmres: (a) Except as olberwlee lemPed in alerts Appendix, 8ushim Assocmle may we or d adore PHI, provided tent Bitch use or disclosure of PHI would not vialoic the Pnvmsy Rules, es follows (i) rs permitted or mcivurd In this Appendix and to the Agmem4td, (it) as odienvire permitted by the Prlvaey/Securuy Ruins; (in; us required by Irw in accordance wrath 45 n_yR 4164 512, (iv) far the proper maiagame t end admmrslrotion arBtismass Associate, (v) to fulfill any pmsent or future legal mponsibilom. (vi) ear Dwo Aggregatlmi wrviecs (P the Plan (ab defined in 43 CFR 1164.S0I )i of (vil) tiny use aced ditclusurc of PHI that has been do-idar dfad wlthln the meaning ar45 CPA § 1641514 (b.) 8ualness Assdeiisc d&ees to doetiment an)' diseidiam ar PHI and the Infarmmfom minded W such dfsalaucs to respand to as a tmilafutg of disclosom or PHI it requested by Employer in soeardaxte with 45 CFR §164MI and to provide sin h dooti mentauon to the Plan as d may request ltom time to time. (c) In the event atat llu*aniq Assoente naintal% FM in a Rem plated Record Set, tlastacss Associate agrees to prwnde aeersss lP such PHI dray h maintains in a designated Accara Set to the Ipdividuol to %ilatn the! PHI relaw in Accordance with 45 CPR 0154.524 Puribmiare, al lira requesl al the Plan, Business Assocmdc agrats to mrdm amendments W PHI that it maintains in a Desigrmled Record Set a9 directed by the Plan and to muirporear any amendmcuts to PHI in ararrdanrm with 45 CM §164 526. (d.) 13"min Associate may disclose PHI to its Agents arsubcontractar3 wdl it Irons tide rased to know suds PHI, but only if.prior to sachdfsalosure, sacb agents er subconimciars provide reAiondble sssanuncos that they wall agree to the some restrictioro and conditions that apply to Busincr Associate with mtilroct to such hit i Infanianmte Use Only: AaiS-FL Agt:atl4umber.' TS Account Na.: Sarvfca Eff. Date: sea, 7-maAt 9 (e.) Business Associate may disclose PHI to other third party vendma provided that Business Asmakitc has received instruction io do so Ibom Employer, Busman Assoeiatc may assume upon instruction firm Employer that the Ihim party vendor nas properiy entered into a Business Associate Apmelocnt where required, 4. Raquired Disclosures aid Use. Business Asststials may disclose the PHI teverded to it by the plan If and to the extent. ilia[ lnW .or court antler requires shalt disrustac. Punier, Business Anacmlo rune s to make its mternnl practu e% boots, land regards, including policsa4 mus procedures, tohstmg to the use oval disclosure of PHI received from or created or received by Hustpess Assockc an behalf of the Plan available to the Set;"", ss requested by the Plot or 4cidi haled by the Secretary, forpurpnees.of the Secretary daterrt ming the Plan's eomplaaace with the Privacy, Rule, 5 Rrgpired lgodte to Nosiness Associate, In accardanamm whir 49 CFR ¢164MO. and fo din orient datsudt a limitation may sffecf Business AsaFin a use or disciosurp arPHl. Employer, w hag an behalf orthe pio% anises to rmfify Boom Assimusk oflsny imatation(s) in its nonce of parry practices. meh dulL without haillation, may ahaoge:a in, or raysaeatton al, pemerssian by,a n Individual to use or dow1we PHI. Employe, acting oes behalf or the Wan, also agrees to nohry Business Ass ews army milrkhon to the use or disclosure of PHl tint fi lads agreed to an acesidmice with 45 CFR 1164..ri22, to the exww That such rwstnclicn wary affect Ausirresc Assacrnte'a use or disclosure afPHI 6, Required Nalh:e to the Plan. Busmen Assoclalc .gpees to report to the Plmr my use or disclosure of PHI odmxise than as provided by this AgmemW (including but notltanitcd to any Seaunly incident) of which It Seconats awaor vrttbtu ten days of baconiuig nvkvm ofeuen use ordirikasure Nooice to one orthe employees designated by Employer in ucn*nco with Saxton C.7 bemm Ylmlt be considered notice to the Plan, I. %dusure to Eisiployees orEraployer. (a.) MOn disolmnE lntbnmdbon to Employer she Plan acknnueledlM also asses Shot Susan ss Associate shall only 61ck sc PHI in its pemsaesiaa ie the employees who two identilled an the Privary Notice chstabuiled by Employer as having access to PHI, in mxatdo im with 43 CFR 1164.SBq(il and tint such disclost res arc mAcly for purposes orerrxsetng out Plan tidminisatraton Ionetlons that Employer pa rtbrtto for Its Group Health Plan, (b.) Cloplayer agrees Ill timely notify business Ax=aote in Writing of any oranges to Use comes arpositions oreroployees tided in tic Privacy Notice and Desjgnated pcnor Listing contained in the slanotaac pop ofthas Appendix. Business Associate shrill have no duty to istqukc whetter the lot of Des;ageahsf remm is Memo (c) Empkiyarsholl indemnity and hold harmless Bushiess Assacntc (and its wooloyros) for any and all liability Basmers Associate logy anew es a result orany rmprape:r use or disclosum of PHI by Employer or a Destgmted Persan(s). flualosew Anoeretr shin inde:mniry and hold harmless Etaployor (red its emphayau) for arty land all Holithly Employer may incur as a result ofamy improper use or dirchmtim at PHI by Business Associate. 8. Electranle Bain Intemboass c. Bibsunen Associate apnea to comply wdh the ED1 standard =11511e1tion requirements set forth in 45 CI•R Parts 160 dnd 163 to the extent applicable 9. Security. As arthe affective date of [his Appaclim, Busmcss Associate will 1 01 Imphxrnnr Pdmmistrntive, Physical mad ledmic al mlbgwu* that reasomobly and oppropfatefv protect pee confidconalhy. imcgnty. and availability of electnmac PFII that K creates, receives, nmtathms, or tmismits an bphtalrorn covered entity as defined by HiPAA; and (b.) F.fatcre Brat any agent or subconkchir to wham it providrs eketranm PHI agrees to implement reasonable and lsppntfwiaa salwards to protect eleclroidc PHI D. Rr5V0xssnitt =0j-AVENToFEn1PWYM 1. scope arRospoodbtRty. If Is agreed and understood that ia(inbsomee perfwans do services set rmih in D 2 on herself of Employer as agent orBmph yer to assist Employer with the obligation to the Plan. All such services sal forth in "Sect,n D 2 um necessary fa assist Employer with Empbsyer's tespanstbdity to the Plan Scope ofSerrlecs. The follawmg services arc perfmmad by Inflnisourra as Agent of Employer: (o) Samicas That racilitale and retort the emallmain and dismnallmeet oremploye is and thfetr eligible dependents in the Plot. (b) Samfees, that thdlitaie the payment of premiums under the Plan 3. Stop of Responalbilifies orAgent of Employer. Intiwouitx, cis Agent ar Employer, agrees ro the same candillow and nztricaione rat forth in Sections C.2 thrauplt C.7 hemp to the extent such intbrrnation received from Employer artgtnsted from die Plan (i.a., fhc information was ogee PHIJ With *egaid to all other individual identifiable health Inratuathork Inremsoutac agrees to use: its beet ei?arls in protect the conlidentlatily crouch inibrination and to only an Such information is ncocseary to pcdbrm servicas c+efe► peied in Section D.2 or as otherwise required or permitted by opts ir,sble low. 4, Elcctroatc Dais laterclrange. Employer acknowledges that Agent of $rnpboyer is under no obligation to conicity .with the EDI s umdard hmnmacthnn reauacments set forth in 45 CFR. parts IN and 162 and tic security ndcs set forth in 45 CFR 11 fr4.302 at seq. with respn:t to smvicn set ferns it, Section D.2 homin In£ttdsource Use; Only. A(IIS-TL Agent lwumber, TS Arntnual No.: Service Ef. . Daur- Ren raa.of infini ource- COBRA Account Setup Form Account information: (Please verify and make any needed cmections) AceL #: Account Name: Mailing Address: fe K�; ht ... MAI lam( AP City: C LN7@iildw State: )'L Zip Code: 3 q / Phoneik L.� .2) oZt{i� �3,�'3 Fas#: (3s 3 7 — 3!2 ,. Number of Ynsar ed Employees: - Z 50 Legal Name of Group Health VW: (Please ' Note: If horn provided Infinisoarce will use, to your Summary Plan Description). Health Plan(s) sponsored by eamperny xame- Contact Information: (Pies se complete if different from agreement) Primary Contact Name: %LQ S,4R j is � Primary Contact Emaf1 Address: i ' QQ C kLmPnff-1 d L Protected Health Information Contact (PHI): Yes or No Address Information (if different from above): Mailing Address: Chy; State: Zip Code: Phone #: Ext.: Fax #: Secondary Contact Name: fge-L Secondary Contact Authorized for Online Access: lease provide an emall address) or No Secondary Contact Email Address: Protected Health Information Contact (PFII): 65) or No Address Information (if different froth above): Mailing Address: S C City: State: , ,lzip Code: �[ Phone #: �35a� �%Z gat.: Fan #: [�� �1 7`14/- Q 3 9J' M COBRA Activity: (Please circle your response) 1. his there anyone on your group health plan that is currently receiving coverage under COBRA 9 or No 2 Are there locations or insured employees that reside in to of California? Location Insured Employees Only None ZA. Is your group health plan currently self insured 7 q la S 3. Does your company sponsor any group health insurance or HMO contract written in the State of Illinois? (To determine if your health insurance contract or HMO coverage provides Illinols continuation, contact the insurance carrier -or the HMO or check your Cerbficale of Coverage,) Yes or V d. Does your company have a Union that administers COBRA in ilaion Employees? Yes or 40 5. General Notice blanket mailing to anyone on the group health plan: The General Notice is a required notice for COBRA. 'It explains the employee's spouse end dependents (if covered) rights and responsibilities under the Federal COBRA law and establishes Event procedures. Would you like Infilmsource to update your currant employees with a blanket mailing of the General Notice? '-%-. *Yes, I would like Infinisource to do the mailing at 53.00 for each General Notice mailed. I will complete the Excel Spreadsheet and return it back to Infinisource (see below) Yes, I would like h1fi nisudree to Complete the Excel Spreadsheet on my behalf and send the mailing for S4.50 per notice mailed. I understand that I will need to supply a list of names and addresser, of everyone currently on my group health plan to Infinisource. No, I would like to conduct my own mailing. I would like Infinisnurce to Send a copy of the General Notice and instructions on that I can Complete my own blanket mailing *If yes: You will receive a Request fo. Ganawl Notice Blanket Mailing Form to sign authorizing latusource to do this retailing. Once we receive this back an Excel spreadsheet will be provided to you by e-mail for so that you may Till in all the names and addresses of the active employees on your group health plans. When you have this completed, you will need to e-mail it back to Infinisoture per the instructions that are provided 6. Has your company been certified for the Trade Adjustment Assistance Act (TAA) by the Depor . n t orLabor? (This is for companies that have experienced a reduction in workforce due to overseas trade.) Yes or N 7. Does your company have an HMO plan? Yes or 8. As we get you started with our COBRA services, do you anticipate any spec"siness challenges in the near future, such as a layoff, that you would want our assistance with? Yes or(140 (If yes, please explain.) 9. Reporting Preference: Online at our website or Paper -based forms (not available with COBRA Direct Service) lit. Do you have i T irm,_l_ d PpM that will be mportiug to ns an your behalf? Yes or Nn 1f"YW', what is the name of that'Ibird Party? Will they be reporting to us an your behalf via "Electronic Data Transrer" (EDT)? Yes or Ito 11. Training: We offer comprehensive Mining calls which are scheduled with one of our Customer Samoa Representatives and up to Eve other clients, You will be contacted and tcheduled for training shortly atler your account is setup. *$77sr T"RA Criterla, for COBR4 regnlres that ilia Individuals responsible for COBRA conspliance arnsr Irave COBRA trniuhig. 12. ODRA of 1989 amended COBRA to allow an.employer to choose an optional extension orCOBRA time ftmes. This provi iton allows employers to calculate the COBRA coverage from the Loss of Cave rae Date instead of the Qualifying Event bate Normally COBRA coverage calculates from the Evcnt Dote, but with your tamer's approval, COBRA coverage can be calculated from the Loss of Coverage Date instead. CWRA cov e wHId then m Coag& 4AMays duck with your ctarrlm prior to using this rule, and'obtaln their appraisal in iW tiug. • Does your company use the OKRA of 1989 Role as specified above? Yes ar No Will you be applying this rule to all ol'your plans? Yes r No If"No", whicb plans would you hike this role applied to? Would you like the expires date to be the last day of the final month as COBRA? (S or No If"Ya', than this will applyto all plans and all events. If you only need one phut or once type of event to expire at the and of the month, we are w—t able to apply that rule atthis time. Brief Report Explanation: (a detailed explanation will be provided dormgyour trainutg) • .r 8tatas Chgagge Haort- Shows additions, changes and removals from COBRA. • h1111211199 AMS M&I. Shows cttrront.status of Qualified Beneficiaries. • Month End Report: Shows notices generated and mailed for the month. • PmM Renuttance/SuMmM, Shows premium payments collected by Inftnisaume. • Rate Renewal Report: Requests now plan mfbrmation at health plan renewal • QQ RA Takeover Repo: Lists COBRA participants that have been reported to infutisoumc. • Plans, and, Rates Report, Verifies plan information received by Infinisouree. • Vqn-clor RMWum Invoice • Shows vouchers processed and -invoices for the 2% administration The retained by lnfiimgource • Refund Renarl. Shows any refunds processed by lnflnisource. • Prior Acftvity Re err Shows Qualifying Event notices seat by Inimisource for events occurmg prior to the service agreement effective date. • Year End Reoort Shows 211 achvity reported to Ir;iinisource for the prior calendar year. ■ HEA_A Month End Report. Shows HIPAA certificates issued by lnfinmsource. Please put a check under the appropriate contact that is to receive each of these required reports. If "Other" is chosen an Account Implementation Specialist will contact you. Reports for clients who choose Premium Collection Service: (Infinisource collecting premiums) Primary Secondary Directly to Carriers Contact Contaiet Other See Next Page.* Daily States Change Report 1l _ s.1 Participant Status Report ✓ ` N14 Month dad Report —y— NIA Promium Remittance (with check) tf Premise Summary (without cheek) '�" Rate Renewal Report NIA COBRA Takeover Report NIA Plans and Rates Report NIA Voucher Premium Invoice L— •� NIA Prior Activity Report �i N/A Year End Report 17_ NIA For HIPAA Certificate Service Clients: HIPAA Mouth Ead Report 1 V � Page 3 of 4 *Please note: if you would like lnfmisotuce to send auy repatEs or rernittances directly to the carolers, we would teed the following information forte carrier. All fields are required. Please use the back etthis man iif_vmt have multiple carriers for direct mppEUM Name orGrrler: Dr Gmup # • Carrier address: • *Cootact person or Department: *Pleost: do not supply us with the name of your salts contact persol . We need the actual person or department that will be proccsdq the enrollment and eligibility regneft ■ Phone Number of Cotttaed0wrier. • Fax tmmber, The carriers must give theirapproval to you, prior to accepting reports directly from Infnisoarm- Reports for clients who do nvt change Prenenm Collection Service: (Client collecting pratulttms) Primary Secondary Contact Contact Other Participant Stains Report Month End Report COBRA Takeover Report Prior Activity Report t Year End Report - Send Service Renewal Invoice to: n Client ti 4pnt or Agency rq Other. If outer, to whom? Address: Please send any additional miscellaneous fee invokes to the fallowing: *(Please see examples below) a Client o Other, if other* to whaln? Takeovem- These are COBRA participants that have been repotted to knfinisomce which we will load into our system and lake over the invoicing of We will also generate MY fatum notices that are necemary, Voueber Premium Invoke fees - From time to time, the Employer may, in its discretion, decide to mate special enangements for premium payments on balmirurpwticipants. In any such case, the client will be required to notify lnfinisourre in writing of any special arrangement. In aadditim the client shall be required to pay a fees associated with such premium payments, a set Witt in the Agreement, including the additional two pine» t (2%) COBRA administration fee authorbed by federal low, as if such preiniums were paid d1 Maly by the qualified be:nctichay. Additional Plans - Up to five plan setups are included in our PremtomCollection annual fee. There may he additional c m%u ifyon have more than five plans. Copyright 07oug taftrdsource, lac. Allrights reserved. This work is protected underdac P. 4 of4 Unauthorized duplieatim, d'r�mdon ar athgfitiaae or the inimnmtion C°Phy an cd °Cabe United orates and alter coenNrics, rewyreaaltincivilliabllltyaadwizriamiprosavt;art.2733 ot.p9