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1998-67 . . EXECUTED COpy THIRD PARTY ADMINISTR4. TOR (TP A) AGREEMENT DATE OF AGREEMENT: April 1, 1998 EMPLOYER: City of Clermont PO Box 120219 Clennont, Florida 34712 TPA: Robey - Barber Insurance Services Corporation 3965 Henderson Blvd. Tampa, Florida 33629 PLAN: City of Clermont Employee Health Benefit Plan This AGREEMENT is made by and between the above named EMPLOYER ( which may include affiliated or subsIdiary employers that become a party hereto) and the above named TP A , as of the date stated above, for perfonnance of certain administration duties and services and other functions of the Plan Administrator in connectIOn with the above PLAt'\¡. The EMPLOYER is the Plan Administrator and is given the proper authority under the PLAN to appoint agents and representatives to act on its behalf and to delegate to such persons any part or all of the functions of Plan Administrator. In consideration of the mutual covenants and tenns and conditions set forth in this AGREEMENT and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, EMPLOYER and TPA agree to the folloWIng. . . THIRD PARTY ADMINISTRATOR AGREEMENT THIS AGREEMENT, made this 1st day of April, 1998, by and between City ofClennont and any other affiliated employer which becomes a party hereto (hereinafter called the "Employer") and Robey-Barber Insurance Services Corporation (hereinafter called the "Third Party Administrator"). WITNESSETH: \VHEREAS, the Employer now provides certain health care and hospitalization coverage for its Employees and their eligible Dependents under the City of Clennont Employee Health Benefit PLAN (hereinafter called the "PLAN"); and \VHEREAS, the Employer is the PLAN Administrator of the PLAN, and is given the authority under the PLAN to appoint agents and representatives to act on its behalf, and to delegate to such agents or representatives any part or all of the functions of the PLAN Administrator; and \VHERE AS, the Employer desires to employ the Third Party Administrator and the Third Party Administrator desires to be employed by the Employer, on the tenns and conditions hereafter set forth, to perfonn the administrative services and duties set forth herein; NO\V, THEREFORE, for and in consideration of the mutual covenants and agreements hereinafter set forth and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties hereto agree as follows; . ' . . SECTION I PLAN & BENEFITS ADMINISTR4. TION DUTIES OF THE THIRD PARTY ADMINISTRATOR 1. Furnish to EMPLOYER periodic statements showing all receipts and disbursements made by the THIRD PARTY ADMINISTRATOR including, but not limited to, a separate statement indicating payments made to or on behalf of Employees and their Dependents (as defined in the PLAN). 2. Assist the EMPLOYER, if requested to do so, with the timely preparation of all reports, tax returns, statements or other documents required to be completed by the EMPLOYER or the Trustee of the PLAN with any local political subdivision, a state government or the federal government or distributed to Employees or their Dependents with respect to the PLAN, including, but not limited to all reports to be filed or distributed pursuant to the provisions of the Employee Retirement Income Security Act of 1974, as amended ("ERISA"). 3. The THIRD PARTY ADMINISTRATOR shall process all appropriate claim charges for benefits in accordance with the tenns of the PLAN with a 98% industry standard accuracy ratio goal. Further, the THIRD P...\RTY ADMINISTRATOR shall perfonn all necessary investigations and assemble all necessary infonnation and documentation necessary to make a detennination as to eligibility and/or to whether a claim for benefits is properly payable under the tenns of the PLAN. The ultimate decision to payor deny a claim, however, lies exclusively with the EMPLOYER and/or PLAN fiduciari~s, and the THIRD PARTY ADMINISTRATOR shall follow all instructions regarding the payment of claims made by the EMPLOYER. 4. Upon the detennination that a claimant is entitled to receive payment of benefits under the PLAN, the THIRD PARTY ADMINISTRATOR shall issue a check or draft upon an account operated by such Administrator for the payment of such benefits as provided for in the PLAN. Such check or draft will be made payable to the claimant, to any physician (as defined in the PLAN) or Hospital (as defined in the PLAN) providing services to or on behalf of the claimant or to whom the benefits have been properly assigned. The THIRD PARTY ADMINISTRATOR will deliver such draft or check issued by the THIRD PARTY ADMINISTRATOR on the PLAN to the PLAN Administrator, along with a copy of an explanation of the benefits paid by such check or draft, to the person or persons designated by the EMPLOYER from time to time to receive such copies. 5. Upon detennination that a claimant for benefits is not entitled to benefits or that an employee or dependent is not eligible for benefits under the PLAN or that the sickness or injury of such employee or dependent is not compensable under the PLAN, in whole or in part, the THIRD PARTY ADMINISTRATOR shall provide written notice to the employee, or to the employee for whose dependent benefits were claimed, setting forth the specific reason or reasons for such demal and such other infonnation as required to be provided under the PLAN, in a manner calculated to be understood by such employee. The THIRD PARTY ADMINISTRATOR shall further notify the employee or dependent whose claim for benefits has been denied of the right to appeal the decision as provided for under the tenns of the PLAN and such other rights as are required by ERISA. Further, the r , THIRD P ARTY ADMn-ß,RA TOR shall provide a copy of such .ces to the person or persons designated by the EMPLOYER to receive such copies. 6. The THIRD PARTY ADMINISTRATOR shall maintain confidentiality on all claims or sensitive medical infonnation received on all Covered Persons for the protection of the Covered Person's privacy, however, records may be examined in the event a Covered Person becomes a party to litigation against the PLAN fiduciary or Employer. DUTIES OF THE THIRD PARTY ADMINISTRATOR COBRA ADMINISTRATION Note: The following items A. through E. DO NOT APPLY if the EMPLOYER has chosen not to employ the THIRD PARTY ADMINISTRATOR to perform administrative duties and services in connection with the requirements of the federal law known as COBRA (The Consolidated Omnibus Budget Reconciliation Act of 1986, as amended) and a "COBRA ADMINISTRt\TION ACKNOWLEDGMENT and AGREEMENT" for this PLAN has been executed by the EMPLOYER. A. The THIRD PARTY ADMINISTRATOR shall establish the EMPLOYER group on Its computer system, customizing the complete series of standard letters required for proper administration and initial notification of existing COBRA participants and accomplish all ofthe compliance functIons related to eligibility detennination and proper notification of COBRA eligible by a method authorized by Federal Regulation. Further, the THIRD PARTY ADMINISTRATOR shall monitor the legally prescribed notification and COBRA election time frames. The THIRD PARTY ADMINISTRATOR assumes complete responsibility for: collection of, accounting for and the distribution of premium; the monitoring of time lines of COBRA premium paymf'nts; the tennination of participants for late payment; reporting to the EMPLOYER of COBRA notifications, elections and tenninations; monthly reporting to the EMPLOYER of all premium collections; detennine ineligibility for dual coverage due to a pre-existing medical condition; detennining length of such eligibility for dual coverage; determine ineligibility for coverage beyond 18 months due to disability; and all other responsibilities that would nonnally be the EMPLOYER's under present law or any amendments to existing Federal statutes. B. The THIRD PARTY ADMINISTRATOR shall pay for all of its own expenses incurred in connection with the perfonnance of its duties there under. However, the EMPLOYER shall reimburse the THIRD PARTY ADMINISTRATOR for extraordinary expenses incurred for addItional or special services requested by the EMPLOYER. The characterization of such special services and associated expenses as extraordinary shall be by mutual consent of the THIRD PARTY ADMll\TISTRATOR and EMPLOYER before such expenses are incurred. C. The THIRD PARTY ADMINISTRATOR shall assist the EMPLOYER, upon wntten request, in establishing "applicable premiums", as defined in the Internal Revenue Code, from which COBRA premiums are derived. The THIRD PARTY ADMINISTRATOR shall not be liable in any proceeding at law or in equity for any challenge to rates established by the EMPLOYER without concurrence as to appropriateness of such rates by the THIRD PARTY ADMINISTRATOR. Similarly, the THIRD PARTY ADMINISTRATOR shall not be liable for any other compliance failure on the part of the EMPLOYER. Further, the EMPLOYER shall reimburse the THIRD PARTY ADMll\TISTRATOR for any expense, loss, damages, or legal fees incurred by the THIRD PARTY ADMINISTRATOR in d8ding any claims or demands arising fr.a challenge to rates established by the EMPLOYER without conCUITence as to appropriateness by the THIRD PARTY ADMINISTRATOR or any other compliance failure on the part of the EMPLOYER. However, the TmRD PARTY ADMINISTRATOR shall be liable for any compliance failure which is due, exclusively, to the actions of the THIRD PARTY ADMINISTRATOR and shall share in liability, with the exception of legal fees, for any challenge to rates or any compliance failure which is due to actions taken in concurrence between the EMPLOYER and the THIRD PARTY ADMINISTRATOR. D. The THIRD PARTY ADMINISTRATOR shall strictly enforce, on behalf of the EMPLOYER, the time limits for certain actions by Qualified Beneficiaries and other limits to this mandated benefit, as defined and prescribed by Federal Regulation, and shall not be liable in any proceeding at law or in equity for any proper enforcement within the Regulations. Further, the EMPLOYER shall be responsible for any expense, loss, damages, or legal fees incurred by the EMPLOYER and the THIRD PARTY ADMINISTRATOR shall be responsible for any expense, loss, damages, or legal fees incurred by the THIRD PARTY ADMINISTRATOR due to an enforcement failure on the part of the THIRD PARTY ADMINISTRATOR. E. The THIRD PARTY ADMINISTRATOR accepts the obligation to defer to the EMPLOYER full and final discretion in settling disputes and appeals that may arise in the course of enforcement of the limitations imposed upon Qualified Beneficiaries by Federal Regulation. The THIRD PARTY ADMINISTRATOR shall be liable in any proceeding at law or in equity ifit falls to defer to the EMPLOYER such full and final discretion. SECTION II COMPENSATION OF THE THIRD PARTY ADMINISTRATOR The THIRD PARTY ADMINISTRATOR shall be entitled to certain fees from the employer, as detailed in the FEE SCHEDULE previously provided to the EMPLOYER, in compensation for the obligations created by this AGREEMENT. Our compensation includes the monthly service fee per employee (paid by the employer) and 2% of collected COBRA premium (paid by the COBRA continuees, if any.) SECTION III DUTIES OF THE EMPLOYER 1. The EMPLOYER shall collect the contributions, if any, to be made by Employees for coverage pursuant to the terms of the PLAN, in the manner it may deem appropriate. The EMPLOYER, on notice from the THIRD PARTY ADMINISTRATOR, shall pay to the THIRD PARTY ADMINISTRATOR such amounts as the THIRD PARTY ADMINISTRATOR shall determine are necessary for proper payment of benefits and/or premiums under the PLAN pursuant to the terms and provisions of the PLAN. . . 2. The EMPLOYER shall assist in the enrollment of Employees in the PLAN, shall advise the THIRD PARTY ADMINISTRATOR with respect to benefits payable under the tenns of the PLAN upon the request of the THIRD PARTY ADMINISTRATOR, and shall transmit any inquiries from Employees with respect to the PLAN to the THIRD PARTY ADMINISTRATOR. The EMPLOYER shall distribute or make available such documents to the Employees, on the advice of the THIRD PARTY ADMINISTRATOR. 3. The EMPLOYER shall verify the eligibility of Employees for benefits pursuant to the tenns of the PLAN and on the application for benefits fonns submitted by Employees to the EMPLOYER pursuant to the PLAN. 4. The EMPLOYER shall enroll new participants and notify the THIRD PARTY ADMINISTRATOR of all tennination's of coverage on a timely basis. In the event that such notice is not timely, the EMPLOYER shall be entitled to a refund of no more than three months ofretroactive premium and fees. 5. The EMPLOYER shall maintain confidentiality on all claims or sensitive medical infonnation received from the THIRD PARTY ADMINISTRATOR or any other source for the protection of the employee's privacy. Any medical infonnation received from the THIRD PARTY ADMIN1STRATOR or any other source should be segregated from personnel files. Any "public disclosure of a pnvate fact" is an invasion of the employee's right to privacy. 6. The EMPLOYER shall also perfonn the following duties to assist the THIRD PARTY ADMINISTRATOR in the administration of COBRA requirements (except that the following items A. through C. DO NOT APPLY if the EMPLOYER has chosen NOT to employ the THIRD P ARTY ADMINISTRATOR to perfonn administrative duties and services in connection with the requirements of COBRA): A. The EMPLOYER shall notify the THIRD PARTY ADMINISTRATOR, in sufficient time to allow the THIRD PARTY ADMINISTRATOR to make proper notification of COBRA rights to the Qualified Beneficiaries within fourteen (14) days of the date they learn of the following "Qualifying Events" (as defined by Federal Regulations): 1. Tennination of employment of a covered employee (for reasons other than gross misconduct of the employee, which shall be the sole detennination of the EMPLOYER in consultation with the THIRD PARTY ADMINISTRATOR regarding current case law defining "gross misconduct" or a reduction in hours that results in loss of coverage; 2. Divorce or legal separation affecting the eligibility of any PLAN participant; 3. Change in the status of dependent children such that they no longer meet the defmition of eligibility under the provisions of the EMPLOYER'S PLAN; 4. Death of a covered employee covering eligible dependents; 5. Any other event resulting in the loss of coverage for any PLAN participant. The EMPLOYER III be deemed to have met the requiremls of this paragraph if notification is mailed to the THIRD PARTY ADMINISTRATOR within seven (7) days and received by the THIRD PARTY ADMINISTRATOR within ten (10) days of the Qualifying Event. The requirements of this paragraph are material in that the THIRD P ARTY ADMINISTRATOR cannot perform its duties under this AGREEMENT without accurate and timely information from the EMPLOYER regarding the status of its employees. The THIRD PARTY ADMINISTRATOR shall not be liable in any proceeding at law or in equity for any notification compliance failure arising from the action or inaction of the EMPLOYER. However, the THIRD PARTY ADMINISTRATOR shall be liable for any notification compliance failure which is due, exclusively, to the action or inaction of the THIRD PARTY ADMINISTRATOR. B. EMPLOYER shall assist the THIRD PARTY ADMINISTRATOR in assuring compliance with the notification requirements of Federal Regulation by advising the THIRD PARTY ADMINISTRATOR if the EMPLOYER has not received a copy of the THIRD PARTY ADMINISTRATOR correspondence to new Qualified Beneficiaries within fourteen (14) days of the EMPLOYER'S notification to the THIRD PARTY ADMINISTRATOR. C. The EMPLOYER shall stand prepared to receive and accept full and final discretion in settling disputes and appeals that may arise in the course of the TIDRD PARTY ADMINISTRATOR's administration of COBRA compliance. 7. EMPLOYER shall pay Robey-Barber's fees, including the annual administration fee, in accordance with the terms set forth in this AGREEMENT. Further, the EMPLOYER shall reimburse the THIRD PARTY ADMINISTRATOR for all additional services, reports and materials provided by the THIRD PARTY ADMINISTRATOR beyond those specifically set forth in by this AGREEMENT. Such additional services, reports and materials shall include, but are not limited to, legal expenses incurred in the course of subrogation, printing of custom check stock, special check handling, special funds handling, non-standard report preparation, reprints of summary PLAN descriptions, charges for checks returned "NSF", late payment expenses and reinstatement fees. 8. EMPLOYER shall provide the THIRD PARTY ADMINISTRATOR with any and all information necessary for the THIRD PARTY ADMINISTRATOR to perform its duties under this AGREEMENT. Such information shall be provided in writing in a timely fashion. Such information shall include, but is not limited to, any and all changes in employee status, changes to the written terms of the PLAN and all other pertinent information. 9. The EMPLOYER shall ensure that its employees and/or dependents of employees fully and accurately complete all enrollment and claim forms submitted for the purpose of enrolling in or seeking benefits under the PLAN. The EMPLOYER shall further ensure that the covered employee or employee's dependent supply all necessary medical information and other information as may be required by the THIRD PARTY ADMINISTRATOR to perform its duties under this AGREEMENT. Further, the EMPLOYER shall ensure that claims for benefits under the PLAN be submitted within ninety (90) days or within such other time as specified in the PLAN, £fom the date the charges were mcurred by the claimant unless the THIRD PARTY ADMINISTRATOR, at the direction of the EMPLOYER, allows later filing of such claims. 10. The EMPLOYER shall hold harmless and indemnify the THIRD PARTY ADMINISTRATOR in connection with any claims or legal actions arising from the THIRD P ARTY ADMINISTRATOR's good faith processing of benefit claims. The EMPLOYER shall reimburse the . . . THIRD P ARTY ADMINMRA TOR for any expense, loss, damage, judgments, awards or legal fees incurred by the THIRD PARTY ADMINISTRATOR in defending any claims, demands for benefits or lawsuits concerning PLAN benefits that have been denied in good faith by the THIRD P ARTY ADMINISTRATOR. SECTION IV TERMINATION 1. This AGREEMENT may be terminated without cause by either the EMPLOYER or the THIRD PARTY ADMINISTRATOR upon thirty (30) days prior written notice given to the other party hereto, to be effective as of a date certain as set forth in such written notice. At least one additional month's Administrative Fees will be charged should the EMPLOYER not provide thirty (30) days written notice of intent to terminate. The "Effective Date" of termination shall be not less than thirty (30) days from the date of such notice. The THIRD PARTY ADMINISTRATOR may terminate this AGREEMENT immediately upon late payment by the EMPLOYER of premium or fees or upon failure by the EMPLOYER to fund claims within ten (10) days of the date c1fiims are ready for payment. Upon the Effective Date, all obligations of the THIRD PARTY ADMINISTRATOR and of the EMPLOYER pursuant to this AGREEMENT shall be terminated and the THIRD PARTY ADMINISTRATOR shall have no further obligation or liability to pay any further benefits to Employees or Dependents of Employees pursuant to the terms of the PLAN from and after the Effective Date. 2. Within sixty (60) days after the Effective Date, the THIRD PARTY ADMINISTR 1\ TOR shall make a complete final accounting including a detailed account of all receipts, disbursements and other transactions with respect to the PLAN performed by the THIRD PARTY ADMINISTRATOR pursuant hereto and shall deliver such complete and final accounting to the person or persons designated by the EMPLOYER. The THIRD PARTY ADMINISTRATOR from and after the date of notice of termination, shall make available to the person or persons designated by the EMPLOYER all of the books and records of the THIRD PARTY ADMINISTRATOR with respect to the duties performed by the THIRD PARTY ADMINISTRATOR pursuant hereto and, at the time of the final accounting, shall deliver to the EMPLOYER all books and records of the administration of the PLAN and all claim files, reports and other papers dealing with the PLAN. 3. After the Effective Date, on anniversary or otherwise, the THIRD PARTY ADMINISTRATOR shall complete settlement of claims submitted prior to the Effective Date. The THIRD PARTY ADMThTISTRATOR reserves the right to offer administrative services to process claims incurred but not yet reported. The THIRD PARTY ADMINISTRATÒR shall be compensated for this service based on fees payable for the last three months prior to the Effective Date. 4. This AGREEMENT may be terminated by the THIRD PARTY ADMINISTRATOR if written renewal confirmation is not received by the EMPLOYER within the fifteen (15) days following the actual renewal date. . SECTION V . REPRESENTATION AND WARRANTIES OF THE THIRD PARTY ADMINISTRATOR 1. The THIRD PARTY ADMINISTRATOR hereby warrants and represents that, during the tel111 of this AGREEMENT, it will not violate any statute, regulation, administrative procedure, ordinance or other law promulgated by the United States of America, by any state or political subdivision thereof, by any foreign country or political subdivision thereof, or by any administrative agency of any of the above. 2. The THIRD PARTY ADMINISTRATOR hereby warrants and represents that it is a corporation duly organized and existing and in good standing under the laws of the State of Florida; that it has full corporate power to cany on its business; and that the execution of this AGREEMENT by the THIRD PARTY ADMINISTRATOR and the EMPLOYER has been duly authorized by the - THIRD PARTY ADMINISTRATOR's Board of Directors and that no further corporate action will be necessary on the part of the THIRD PARTY ADMINISTRATOR to make this AGREEMENT valid and binding upon the THIRD PARTY ADMINISTRATOR in accordance with its tel111s. SECTION VI REPRESENTATION AND WARRANTIES OF THE EMPLOYER 1. The THIRD PARTY ADMINISTRATOR hereby warrants and represents that, should the EMPLOYER decline the THIRD PARTY ADMINISTRATOR's Certificate of Coverage service, the EMPLOYER agrees to hold harmless the THIRD PARTY ADMINISTRATOR for any problems, complaints or actions which may result from any situation relating to Certificates of Coverage. SECTION VII MISCELLANEOUS 1. If during the operation of the PLAN, the United States, the government of any state or any political subdivision or instrumentality of either, shall assess any tax against the PLAN and the THIRD PARTY ADMINISTRATOR is required to pay such tax, the THIRD PARTY ADMINISTRATOR shall be reimbursed for such payment by the EMPLOYER. 2. The EMPLOYER is required to pay premiums as billed. If there are any adjustments to be made to the bill, they will be reflected on the following month's bill. Ifthere is greater than a 10% adjustment to be made to .bill, the EMPLOYER may request thaleViSed bill be generated. A revised bill will only be generated at the EMPLOYER's request and only if the adjustment is greater than 10%. 3. Any notices which are specifically required to be given in writing pursuant to this AGREEMENT shall be deemed to have been duly given if delivered or if mailed, by United States certified or registered mail, prepaid, to the parties at the addresses stated in this AGREEMENT (or at such other addresses as shall be given by either party to the other): Any notice or communication to be given by either party hereto to the other pursuant to this AGREEMENT which is not specifically required to be given in writing, shall be given by telephone by and to any individual designated in writing by the THIRD PARTY ADMINISTRATOR or the EMPLOYER to receive such notices, followed by a written confirmation of such notice or communication, at the address or addresses furnished in writing by one party to the other from time to time. 4. Robey-Barber may negotiate with providers and facilities to obtain discounts on non- network claims as an added benefit. The PLAN will receive additional savings for a fee of up to 35% ofthe savings, depending on the vendor used (of which the THIRD PARTY ADMINISTRATOR may receive up to 5% of the 35% fee to cover the additional administrative work involved in obtaining the discounts and savings). The vendor used may be a related party to the THIRD P ARTY ADMil\1JSTRATOR. Claim turnaround time may be delayed an additional 5 working days during discount negotiations and all fees and savings will be disclosed. 5. Pursuant to this AGREEMENT, the THIRD PARTY ADMINISTRATOR only obligates itself to provide third party administration services to the EMPLOYER. The THIRD PARTY ADMINISTRATOR is not an insurer and has no obligations to pay benefit claims out of its assets or revenues. All benefit claims shall be paid out of the PLAN assets. 6. Notwithstanding anything contained herein to the contrary, the THIRD PARTY ADMINISTRATOR and EMPLOYER are independent contractors and shall not in any way be considered agents, servants or employees of, or joint venturers with, each other. 7. While the THIRD PARTY ADMINISTRATOR shall provide ministerial services as herein required, it shall not be a fiduciary with respect to the PLAN. The ultimate decision to pay benefit claims lies with the EMPLOYER and/or other PLAN fiduciaries and the THIRD P ARTY ADMINISTRATOR will follow all instructions regarding the payment of claims issued by the EMPLOYER. 8. This AGREEMENT contains the entire agreement between the parties hereto with respect to the transactions contemplated herein; and this AGREEMENT supersedes all prior agreements or understandings; whether verbal or written, between the parties hereto relating to the subject matter hereof. 9. This AGREEMENT and any provision hereof may be modified, amended or superseded only in writing signed by both parties hereto. 10. This AGREEMENT shall be binding upon the parties hereto, their successors and assigns, and shall not be assignable by either party without the written consent of the other. . . 11. This AGREEMENT may be executed in one or more counterparts, each of which shall be deemed an original, but all of which together shall constitute one and the same instrument. 12. Captions and section headings used herein are for convenience only and not part of this AGREEMENT and shall not be used in construing it. 13. This AGREEMENT shall be construed and enforced in accordance with the laws of the State of Florida to the extent not preempted by ERISA or other applicable federal law, which shall otherwise control. Should any provision of this AGREEMENT be held invalid by any court or competent jurisdiction, such finding shall not invalidate the remainder of the AGREEMENT. 14. Any agreements for services made between managed care vendors (i.e., Hospital Audit Companies, PPO's, EPO's, HMO's, Large Case Management Companies, Pre-certification UR./Concurrent Stay Review Companies, etc.) and Robey-Barber Insurance Services Corporation to protect and/or conserve PLAN assets will also be deemed as agreements between the managed care vendor(s) and the EMPLOYER or PLAN. Robey-Barber Insurance Services Corporation will be held hannless for any problems, complaints, or actions, which may result from services and/or insurance coverages provided by these independent vendors. SECTION VIII PREMIUM BILLING AND REMITTANCE The THIRD PARTY ADMINISTRATOR shall produce billing statements for the EMPLOYER as follows: Monthly Statements will be mailed approximately, the third week of each month, with the premium due date being the first of the month following. Reminder notices are issued one week following the due date. Termination notices accompanied with possible reinstatement charges are produced at the end of the month. This billing schedule is dictated by the practices of the Reinsurance carriers on Self-Funded plans. Reinsurers, typically, do not allow a grace period and upon termination many of them require a late fee as well as a reinstatement charge. . . EXHIBIT FOR COMPENSATION TO TIDRD PARTY ADMINISTRATOR In Compliance with Section II EMPLOYER NAME: City of Clermont RENEWAL DATE: April 1, 1998 MONTHLY FIXED COSTS Life/ AD&D Premium per $1,000: Dependent Life Premium: * Specific Premium: * Aggregate Premium: ** Agent Compensation: (Percentage of Net Paid as Fee) TP A Service Fees - Medical: Utilization Review Service Fee: MC2000 SmartChoices: Prescription Card Service Fee: Dental Service Fee: MACFP A Fee: EOB's Fee: Certificates of Creditable Coverage: Vision Fee: Flex Fee: COBRA Fee: PPO Access Fee: Monthly Totals (Not including Life) Per Employee Per Dependent N/ A ~~~P);ลก~4b.~~? ::<~ - ""<.?~"""'.-;::~~:ti.",,...... N/A $36.05 N/A $3.00 $10.00 $1.75 N/A $.25 $2.00 N/A N/A $.50 N/A N/A $.25 $3.00 $ 50.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $ 36.05 Annual Administrative Fee: N/A PPO Directory Cost: N/A Large Case Management $110.00/Hour * Rates include Agent/General Agent & TP A Compensation, if any. ** Consultant Fees are classified as "sub-agent fees" under ERISA and DOL guidelines. . .' . . , . . IN WITNESS WHEREOF, the parties hereto have duly executed this Agreement as of the day and the year first above written. BY: City of Clermont hlí¿£IlJ 11. It-t'l- /"/) '1"1/ . ~RINT NAME AND TITLE 4/4~ SIGNATURE ----- ATTEST: Q~L~ fl¡..~,..t¡: IJ /1\, ); ( f ~ -" TITLE BY: ROBEY-BARBER INSURANCE SERVICES Timothy R. Barber. President :ZR PRINT NAME AND TITLE ~~.ïr~ SIGNATURE ATTEST: ~~~GNATURE U OUY\ \.-~ TITLE EXECUTED COpy