BASIC COBRA. Thank you for choosing BASIC for your COBRA Administration! Please read the information below before you proceed with implementation.

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1 BASIC COBRA Thank you for choosing BASIC for your COBRA Administration! Please read the information below before you proceed with implementation. To provide you with the highest quality service, all information will need to be received 14 days prior to the effective date with BASIC. COBRA Setup Packet Instructions: System Requirements to save document: Adobe Standard version 8 or higher Older versions or reader only, you can fill in forms then print when complete. Free online PDF Editor Click on start now (no need to register) Click on Start, Using Unregistered Following on screen instructions Once completed click on save & download Step 1: Please save this file to your system before completing the forms. 1) Client Information Form 2) COBRA Start up Information form 3) COBRA Carrier Information Form (one needed for each policy) 4) COBRA CCP Form(only needed if anyone currently on COBRA) NOTES: If you have an HRA, you will need to complete one (1) COBRA Carrier Information Form for each HRA benefit. Please indicate what policy the HRA is linked to in the field regarding plan name during open enrollment. Step 2: Submitting your forms. You will need to sign the COBRA Administration Agreement and Business Associates Agreement and return to BASIC. 1. BASIC prefers that you securely submit the employer setup packet via our Secure Upload: Use the BASIC Web Portal for secure and encrypted delivery at Follow the easy directions to deliver your company s set up information in a secure manner. You can upload a maximum of five files at a time. -OR- 2. To send the employer setup packet by mail use: BASIC Sales 9246 Portage Industrial Dr Portage, MI If you have any questions, please call (800) ext 3 and a member of our sales support team will be happy to assist you.

2 Client Information BASIC SALES 9246 Portage Industrial Dr Portage MI P ext 3 F los=new Please type or print all information COMPANY INFORMATION Date completed: Legal Company Name: Current Client information below on file (if any changes please complete below) DBA/AKA: Employees refer to your company as: Website: Mailing Address: Please indicate service(s) provided by BASIC. C - Current service N - New service City, State, Zip: Physical Address (if different): City, State, Zip: Main Phone: EMPLOYER CONTACT INFORMATION Fax: COBRA Dep. Verification FMLA FSA HR Outsourcing HR Services HRA HRIS HSA Parking Payroll Retiree Billing Unemployment Executive Name: Title: Phone: Ext: Address: Authorized Representative: Title: Phone: Ext: Address: HR Manager/Director: Title: Phone: Ext: Address: Billing Contact: Title: Phone: Ext: Address: REFERRAL SOURCE (How did you hear about BASIC) Company Name: Contact Name: Address: Phone: : Revised

3 BASIC COBRA Start Up Information Page 1 of 2 BASIC SALES 9246 Portage Industrial Dr Portage MI P ext 3 F Upload to Secure site om/?los=new Please type or print all information ADMINISTRATION INFORMATION (COBRA contact needs to be someone from the Employer) Legal Company Name: COBRA contact person: Title: Phone: Ext: Fax: Proposed Effective Date with BASIC: Number of W-2 employees (include full time & part time): Number of Insured Employees (Required): Do you have anyone on COBRA currently? If yes*, how many *Please complete a Current COBRA Participant Form for each participantadditional fee(s) apply Do you offer a Cafeteria Plan with Flexible Spending Accounts? If yes, what is the Plan Year? Do you offer an HRA account (Health Reimbursement Arrangement)? If yes, you will need to complete one insurance form for each HRA Benefit Is your company required by the state to offer COBRA on Life Insurance*? *Minnesota is the only state required to offer Life Insurance If yes, please provide plan name: BASIC to mail Employer pre-assembled open enrollment and/or SBC packet to COBRA participants (additional fees apply) Do Initial Notices need to be provided to current employees? These are required for all employees or everyone enrolled on health plans prior to the effective date of BASIC COBRA administration. You can do them at no cost by linking to the Department of Labor Sample Notices located or BASIC can create and mail them also for a nominal fee. Do you have Qualifying Event Notices that need to be sent? For qualifying events prior to the effective date of BASIC COBRA administration use the Department of Labor Sample Notice located at Please continue to page two of Start up information Form

4 BASIC COBRA Start Up Information Page 2 of 2 BASIC SALES 9246 Portage Industrial Dr Portage MI P ext 3 F Upload to secure site om/?los=new INSURANCE PLANS What date are termed employees removed from the insurance(s) Plans? End of Month Date of Termination Please list below the number of each type of plan offered to your employees (Primary Medical Plan(s) that may include Dental, Vision and/or RX, or Stand alone Dental/Vision) Number of Primary Medical Plan(s)*offered *that may include Rx, Dental and/or vision Number of Stand Alone Dental Plans offered Number of Stand Alone Vision Plans offered Number of Stand Alone Rx Plans offered Number of Other Plans offered Other Plan Name(s) Will there be a data feed? Yes No If yes, please provide the following Vendor Information: Company Name: Contact Person: Phone: Additional Comments/ Special Circumstances: Revised

5 COBRA Carrier Information BASIC SALES 9246 Portage Industrial Dr Portage MI P ext 3 F Upload via our secure site om/?los=new Please type or print all information INSURANCE INFORMATION Legal Company Name: Insurance Company Name: State insurance contract was written: Policy number: Is this plan Self Funded? What is this plan called during open enrollment? Claims address: Claims City, State, Zip: Customer service number: Effective date of rates: Last day of rates: Type of insurance plan: Are plans bundled? May participants convert to an individual policy at the end of COBRA term? Dependent children are termed on what Birthday: If they are a full time student: Rates Please enter all that apply even if no one currently is enrolled in level of coverage: (Do not include the 2%) Note: Please complete this form once for each insurance policy you have. Single 2 Person Family Family Continuation EE plus spouse EE plus child(ren) EE plus one EE plus two EE plus three EE plus four + Age Based Please send in rate sheet with this form If you do not find your rating structure above please complete Other, give rate amount and description Other Revised

6 COBRA Carrier Information BASIC SALES 9246 Portage Industrial Dr Portage MI P ext 3 F Upload via our secure site om/?los=new Please type or print all information INSURANCE INFORMATION Legal Company Name: Insurance Company Name: State insurance contract was written: Policy number: Is this plan Self Funded? What is this plan called during open enrollment? Claims address: Claims City, State, Zip: Customer service number: Effective date of rates: Last day of rates: Type of insurance plan: Are plans bundled? May participants convert to an individual policy at the end of COBRA term? Dependent children are termed on what Birthday: If they are a full time student: Rates Please enter all that apply even if no one currently is enrolled in level of coverage: (Do not include the 2%) Note: Please complete this form once for each insurance policy you have. Single 2 Person Family Family Continuation EE plus spouse EE plus child(ren) EE plus one EE plus two EE plus three EE plus four + Age Based Please send in rate sheet with this form If you do not find your rating structure above please complete Other, give rate amount and description Other Revised

7 COBRA Carrier Information BASIC SALES 9246 Portage Industrial Dr Portage MI P ext 3 F Upload via our secure site om/?los=new Please type or print all information INSURANCE INFORMATION Legal Company Name: Insurance Company Name: State insurance contract was written: Policy number: Is this plan Self Funded? What is this plan called during open enrollment? Claims address: Claims City, State, Zip: Customer service number: Effective date of rates: Last day of rates: Type of insurance plan: Are plans bundled? May participants convert to an individual policy at the end of COBRA term? Dependent children are termed on what Birthday: If they are a full time student: Rates Please enter all that apply even if no one currently is enrolled in level of coverage: (Do not include the 2%) Note: Please complete this form once for each insurance policy you have. Single 2 Person Family Family Continuation EE plus spouse EE plus child(ren) EE plus one EE plus two EE plus three EE plus four + Age Based Please send in rate sheet with this form If you do not find your rating structure above please complete Other, give rate amount and description Other Revised

8 COBRA Carrier Information BASIC SALES 9246 Portage Industrial Dr Portage MI P ext 3 F Upload via our secure site om/?los=new Please type or print all information INSURANCE INFORMATION Legal Company Name: Insurance Company Name: State insurance contract was written: Policy number: Is this plan Self Funded? What is this plan called during open enrollment? Claims address: Claims City, State, Zip: Customer service number: Effective date of rates: Last day of rates: Type of insurance plan: Are plans bundled? May participants convert to an individual policy at the end of COBRA term? Dependent children are termed on what Birthday: If they are a full time student: Rates Please enter all that apply even if no one currently is enrolled in level of coverage: (Do not include the 2%) Note: Please complete this form once for each insurance policy you have. Single 2 Person Family Family Continuation EE plus spouse EE plus child(ren) EE plus one EE plus two EE plus three EE plus four + Age Based Please send in rate sheet with this form If you do not find your rating structure above please complete Other, give rate amount and description Other Revised

9 COBRA Carrier Information BASIC SALES 9246 Portage Industrial Dr Portage MI P ext 3 F Upload via our secure site om/?los=new Please type or print all information INSURANCE INFORMATION Legal Company Name: Insurance Company Name: State insurance contract was written: Policy number: Is this plan Self Funded? What is this plan called during open enrollment? Claims address: Claims City, State, Zip: Customer service number: Effective date of rates: Last day of rates: Type of insurance plan: Are plans bundled? May participants convert to an individual policy at the end of COBRA term? Dependent children are termed on what Birthday: If they are a full time student: Rates Please enter all that apply even if no one currently is enrolled in level of coverage: (Do not include the 2%) Note: Please complete this form once for each insurance policy you have. Single 2 Person Family Family Continuation EE plus spouse EE plus child(ren) EE plus one EE plus two EE plus three EE plus four + Age Based Please send in rate sheet with this form If you do not find your rating structure above please complete Other, give rate amount and description Other Revised

10 Current COBRA Participant Information BASIC SALES 9246 Portage Industrial Dr Portage MI P ext 3 F Upload via our secure site om/?los=new Please type or print all information PARTICIPANT INFORMATION Legal Company Name: Name: Address: City, State, Zip: Social Security Number: Gender: Date of Birth: COBRA PLAN INFORMATION Date COBRA accepted: Reason*: *If reason is termination of employment please specify if voluntary or involuntary Please click on the link below if you need additional forms: Current COBRA Participant Form.pdf Hire date: Employee s original effective date of insurance: Name of Medical plan enrolled in: Name of Dental plan enrolled in: Name of Vision plan enrolled in: Name of Rx plan enrolled in: Name of Other plan enrolled in: Premiums paid through: COBRA start date: Level of coverage: Level of coverage: Level of coverage: Level of coverage: Level of coverage: OTHER COBRA EVENTS EXPERIENCES (select all that apply): Disabled (determined by social security) Multiple qualifying event: Employees death Divorce/legal separation Medicare entitlement Loss of dependent status DEPENDENT INFORMATION: Relationship First/Last Name Birth Date Revised

11 AGREEMENT FOR ADMINISTRATION This Agreement is made between Benefit Administrative Services International Corporation ( BASIC or COBRA Recordkeeper ) and ( Employer ). COBRA Recordkeeper assists nongovernmental employers in complying with the Consolidated Omnibus Budget Reconciliation Act ( COBRA ) provisions of Sections 601 to 608 of the Employee Retirement Income Security Act and state and local governmental employers in complying with the COBRA provisions of Section 2201 to 2208 of the Public Health Service Act. Employer certifies that it is a non-church entity that employed twenty (20) or more full-time (and/or full-time equivalent) employees on more than fifty percent (50%) of its business days during the preceding calendar year, and therefore, is subject to COBRA as applied to any group health dental and or vision plan(s) offered to Employer s eligible employees, their spouses and/or eligible dependents (collectively, the Health Plan or Plan ). IN CONSIDERATION of the mutual promises set forth in this Agreement, COBRA Recordkeeper and Employer agree to the provisions set forth below. SECTION I: SERVICES PROVIDED COBRA Recordkeeper shall assist the Employer who shall be the named Plan administrator (as defined in ERISA) of the Health Plan in carrying out the Employer s duties and responsibilities regarding health plan continuation coverage applicable to the Health Plan as required by Part 6 of Title I of ERISA, as amended. COBRA Recordkeeper shall not be designated as the Plan administrator or a named fiduciary (as those terms are defined in ERISA) of the Health Plan. Specifically, COBRA Recordkeeper agrees to: 1.01 Perform the initial notification of COBRA rights within fourteen (14) days after the later of (1) receiving written notification of a new hire by Employer or (2) the date the new hire commences participation in Employer s Health Plan; provided all information is completed as requested on the Initial Notification Form Perform notification on behalf of the Plan administrator to affected qualified beneficiaries following the occurrence of a qualifying event as defined in COBRA as it relates to the Health Plan. The notification to qualified beneficiaries described in this paragraph shall be performed no later than fourteen (14) days after COBRA Recordkeeper is notified of the qualifying event by the Employer. This notification shall include mailing required notices and all future billings, collection premiums, mailing notices of conversion options and cancellation of coverage, reporting to Employer and recordkeeping; provided all information is completed as requested on the Qualifying Event Notification Form Provide Employer with reports confirming that the proper notice has been given to qualified beneficiaries and to provide other reports and documentation to keep Employer informed of COBRA Recordkeeper s compliance with this Agreement Provide current and updated information to Employer regarding compliance with COBRA, including any changes or modifications to COBRA and the steps required to comply with the changes. 1

12 1.05 Attend any audit held by the Internal Revenue Service, Department of Labor or any governmental agency/bureau regarding Employer s compliance with COBRA and provide at the audit or hearing records and documentation demonstrating compliance with COBRA Perform any and all duties as required by Attachment A - Summary of COBRA Procedures. SECTION II: DUTIES OF EMPLOYER 2.01 To provide to COBRA Recordkeeper s home office via our secure web portal, all of the following information as it relates to Employer s employees, their spouses and eligible dependents loss of coverage under the Group Health Plan: (a) The death of a covered employee. (b) The termination (other than by reason of the employee s gross misconduct) of a covered employee s employment. (c) The reduction of hours of a covered employee s employment. (d) The divorce or legal separation of a covered employee from the employee s covered spouse. of Medicare. (e) A covered employee becoming entitled to benefits under Part A or Part B (f) A covered dependent child ceasing to be a dependent child under the terms of the Health Plan. (g) Bankruptcy reorganization under Title 11 for persons with retiree health coverage if the bankruptcy causes a substantial loss of coverage within one year before or after the filing. (h) Any other information relevant to the fulfillment of this Agreement as is necessary for compliance with COBRA, as amended. If notice of the foregoing events is not provided to COBRA Recordkeeper in a timely manner (in no event later than 30 days following the occurrence of the qualifying event), COBRA Recordkeeper shall nevertheless make a reasonable effort to fulfill the Employer s requirement to provide covered employees, their spouses and eligible dependents (the Qualified Beneficiaries ) with notice of the right to elect continuation coverage within the 60-day election period set forth in ERISA Sec In the event the late notification to COBRA Recordkeeper causes the notice to the Qualified Beneficiaries to be sent later than the required notification date, the Employer acknowledges the following: 1. The 60-day election period shall commence on the date the election notice is sent to the Qualified Beneficiaries. 2. Any penalties relating to the late provision of the requisite notice shall be the sole responsibility of the Employer. 3. The Employer shall be solely responsible and shall hold COBRA Recordkeeper harmless for any action or failure to take action for failing to give timely notice of each Qualified Beneficiary s right to elect continuation coverage. 4. The Employer shall be liable for and shall protect and defend at its cost, save, hold harmless and indemnify COBRA Recordkeeper and its agents and employees from 2

13 and against all fines, penalties, losses, damages, costs, expenses, reasonable attorney fees and court costs suffered by COBRA Recordkeeper, its agents and employees for which COBRA Recordkeeper may be held or become liable attributable to sending the late notice. 5. COBRA Recordkeeper shall have no liability for any damages to participants resulting from Employer s failure to give COBRA Recordkeeper timely notice of a qualifying event, and Employer shall protect, defend at its cost, save and hold harmless and indemnify COBRA Recordkeeper from any such damages, costs, expenses, reasonable attorney fees and court costs The Employer will provide COBRA Recordkeeper with up-to-date, pertinent information relating to the Health Plan on the effective date of the Agreement and at the time of any later Plan modifications by Employer. Specifically, Employer must notify COBRA Recordkeeper when the Employer is no longer subject to COBRA (for example, if the Employer satisfies the small plan exception to COBRA because the Employer ceases to employ at least twenty (20) full-time [and/or full-time equivalent] employees on more than fifty percent (50%) of its business days during a calendar year). The parties agree that COBRA Recordkeeper may rely on and act in accordance with any information or other instruction believed by COBRA Recordkeeper in good faith to be genuine and properly given The Employer will perform any and all other duties as required in Attachment A The Employer shall be solely responsible to notify carrier(s) of additions and terminations. BASIC has no responsibility or authority to determine health plan eligibility and coverage PLEASE NOTE: To provide more efficient service, BASIC will need a minimum of 14 days to set up a new client after all information has been received. For a takeover from another Administrator, extra time is necessary to ensure the smooth transition to BASIC. As a result, 30 days is the minimum set up time. For BASIC to assume COBRA liability, the completion of all necessary set up information is required before COBRA service can begin. SECTION III: ADMINISTRATIVE CHARGES 3.01 Administrative Charges for Services. (a) As compensation for the administrative services rendered by COBRA Recordkeeper under this Agreement during an Agreement Year (as defined in Section 5.01 below), the Employer agrees to pay to COBRA Recordkeeper fees for services as set forth in the Fee Schedule. Such fees shall be remitted to COBRA Recordkeeper within ten (10) days of receipt of the billing statement for said services. A current Fee Schedule is attached to this Agreement. (b) Not less than thirty (30) days prior to the last day of the first and each succeeding Agreement Year, COBRA Recordkeeper may specify in writing a revision to the Fee Schedule for the succeeding Agreement Year. Such revisions shall replace the Fee Schedule for the next succeeding Agreement Year. If no revisions are sent to Employer, the Fee Schedule in effect for the current Agreement Year shall remain in effect for the succeeding Agreement Year. Agreement. (c) Any unpaid fees shall be immediately due upon termination of this SECTION IV: RELATIONSHIP OF PARTIES 4.01 Relationship of Parties. 3

14 (a) The parties intend that an independent contractor relationship shall be created by this Agreement. COBRA Recordkeeper shall have exclusive control and direction over its work. COBRA Recordkeeper is not an agent or employee of Employer for any purpose, and the employees of Employer are not employees of COBRA Recordkeeper. It is understood that COBRA Recordkeeper may, in its sole discretion, enter into an agreement for similar services to be performed for other employers while this Agreement is in effect with Employer. Further, nothing set forth in this Agreement shall be construed as creating a partnership, joint venture or agency relationship between Employer and COBRA Recordkeeper. (b) Neither this Agreement nor the performance of duties pursuant to this Agreement, shall be construed as the appointment of COBRA Recordkeeper as an administrator as defined in (3)(16)(A) of the Employee Retirement Income Security Act of 1974 (ERISA) or a fiduciary as defined in 3(38) of ERISA. COBRA Recordkeeper s duties and responsibilities shall be limited to those provided under the terms of this Agreement and applicable attachments to this Agreement. SECTION V: TERMINATION OF AGREEMENT 5.01 Termination of Agreement. (a) The initial term of this Agreement shall be in effect for a consecutive twelve (12) month period which begins on the effective date of this Agreement. Following the initial term, this Agreement may be terminated by either party by sending written notice by certified mail, return receipt requested, to the other party. Unless mutually agreed by the parties to the contrary, termination shall be effective thirty-one (31) days after receipt of said notice or the date specified in the notice, whichever is later. (b) In the event of termination of this Agreement by either party, COBRA Recordkeeper shall process notifications until the end of normal working hours on the effective termination date. Notifications not processed by the end of normal working hours on the effective termination date shall be returned to the Employer within forty-eight (48) hours of the termination date. (c) COBRA Recordkeeper retains the right to immediately terminate this Agreement effective as of the date the Employer fails to perform any of its duties and responsibilities in accordance with the provisions of this Agreement, including its duty to pay administrative fees when due as required by Section In that event, COBRA Recordkeeper shall send Employer written notice of the termination five (5) business days before the termination date. (d) In the event this Agreement is terminated as stated in 5.01(a), COBRA Recordkeeper will refund any unused fees. SECTION VI: GENERAL PROVISIONS 6.01 COBRA Recordkeeper s and Employer s Liabilities. (a) COBRA Recordkeeper s liability under this Agreement is limited to the performance of the services (described in Section I) required during the term of this Agreement in accordance with the latest provisions of COBRA and to the Employer Hold-harmless for failure to act in accordance with COBRA provisions. COBRA Recordkeeper agrees to perform these services in accordance with the procedures prescribed by COBRA Recordkeeper. Employer shall be solely responsible and shall hold COBRA Recordkeeper harmless for any action or failure to take action for compliance matters arising prior to the effective date of this 4

15 Agreement. In no event shall COBRA Recordkeeper be liable for benefits under any plan or for any other payment except as expressly stated in this Agreement. The Employer shall be liable for and shall protect and defend at its cost, save, hold harmless and indemnify COBRA Recordkeeper and its agents and employees from and against all fines, penalties, losses, damages, costs, expenses, reasonable attorney s fees and court costs suffered by COBRA Recordkeeper, its agents and employees for which COBRA Recordkeeper may be held or become liable except to the extent prohibited by law and except to the extent occasioned by COBRA Recordkeeper s gross negligence or willful misconduct. COBRA Recordkeeper shall have no liability for any damages to participants in any plan resulting from decisions of the Employer not to provide required notices, and Employer shall protect, defend at its costs, save, and hold harmless and indemnify COBRA Recordkeeper from any such damages, costs, expenses, reasonable attorney s fees and court costs. The Employer shall have no liability for any damages to COBRA participants in the Plan resulting from decisions of COBRA Recordkeeper and COBRA Recordkeeper shall protect, defend at its cost, save and hold harmless and indemnify the Employer from any such damages, costs, expenses, reasonable attorney's fees and court costs. Under no circumstance will either party be liable to the other in a breach of contract claim for any incidental, consequential and/or punitive damages. (b) The Employer shall also assume the liability for any assessment of taxes based upon the existence of any plan including all fines, penalties, losses, damages, costs, expenses, reasonable attorney s fees and court costs incurred in connection with such assessment. Furthermore, if COBRA Recordkeeper shall pay, pursuant to the demand of an appropriate state or federal office, taxes based on the amounts paid into or from any plan, the Employer shall reimburse COBRA Recordkeeper upon demand in the full amount of such taxes paid, including any interest and penalties added to said taxes and paid by COBRA Recordkeeper, provided that Employer has been given reasonable prior notice of the demand and the demand is final and unappealable or not timely appealed by Employer. (c) If an employee of Employer files any type of claim, lawsuit or charge against Employer and/or COBRA Recordkeeper, alleging a violation(s) of law, Employer and COBRA Recordkeeper shall cooperate with the other s defense of such claim, lawsuit or charge. Employer and COBRA Recordkeeper shall make available to each other upon request any and all documents that either party has in its possession that relate to any such claim, lawsuit or charge. This provision, however, shall not preclude the raising of cross claims or third party claims between Employer and COBRA Recordkeeper if the circumstances justify such proceedings. The parties agree that this provision shall survive the termination of this Agreement Return of Materials. Subject to Section 6.07(k), upon termination of this Agreement as set forth in Section V above, Employer agrees to return to COBRA Recordkeeper, via UPS or similar commercial delivery, all manuals, forms and copyrighted material within fourteen (14) days following the termination date Confidentiality. Except as otherwise provided in this Agreement, all files, data and information relating to the business of either party in the possession of the other party will be deemed confidential and will not be disclosed except upon lawful order of a court or public authority which order compels obedience under penalty of contempt or fine or impairment or loss of the right to do business. In the event of any such disclosure, the disclosing party shall immediately notify the other party in writing detailing the circumstances of and extent of such disclosure Governing Law and Arbitration. This Agreement shall be governed by and interpreted in accordance with the laws of the State of Michigan to the extent that such laws are not preempted by federal law. In the event that any disagreement or controversy arises under the terms and conditions of this Agreement, then and in that event such disagreement or 5

16 controversy shall be submitted to the American Arbitration Association, Commercial Arbitration Division and shall be arbitrated in Kalamazoo County pursuant to the rules, procedures and regulations of the American Arbitration Association. The decision of the arbitrator shall be final and binding on the parties to this Agreement Entire Agreement and Notice. (a) This writing shall constitute the entire Agreement of the parties. This Agreement supersedes all prior or contemporaneous written or oral understandings and agreements, and may not be added to, modified or waived in whole or in part except by a writing signed by both parties to the Agreement. (b) For purposes of this agreement, a signed copy delivered by facsimile or electronically shall be treated by the parties as an original of this agreement and shall be given the same force and effect. (c) Whenever written notice is required under the terms of this Agreement, it shall be delivered to the appropriate party by first class mail at the following address: BASIC Employer: 9246 Portage Industrial Dr Portage, Michigan Miscellaneous Provisions. (a) Each party represents and warrants to the other that execution of and the parties performance of obligations under this Agreement have been duly authorized by their respective entities and that this is a valid and legal Agreement that is binding on each party and enforceable in accordance with its terms. (b) Each provision in this Agreement is separate. If any provisions of this Agreement are ever held by a court to be unreasonable, the parties agree that this Agreement shall be enforced to the extent it is deemed to be reasonable and in such a manner as to make this Agreement, as modified, legal and enforceable under applicable laws, and the balance of this Agreement shall not be affected, the balance being construed as severable and independent. (c) Either party s failure to exercise, or delay in exercising, any power or right under this Agreement shall not operate as a waiver, nor shall any single or partial exercise of any such right or power preclude any other or further exercise thereof or the exercise of remedies otherwise available in equity or at law. (d) This Agreement may be executed in one or more counterparts, each of which will be deemed to be an original but all of which together will constitute one and the same instrument. (e) Neither this Agreement nor any of its benefits or obligations are assignable without written consent of the other party. 6

17 SECTION VII NUMBER OF QUALIFYING EVENTS If the Employer experiences Qualifying Events during a 12-month period effective from the date of the contract, in excess of 20% of the employees on the health plan, there will be an additional fee of $15 per qualifying event over 20% turnover. Effective date is. (BASIC reserves the right to modify this date based on facts and circumstances.) EMPLOYER: Dated: By: Title: BASIC: Dated: By: Title: S:\261\SDOCS\BASIC\ben.ad.agr.COBRA 2/25/13.doc 7

18 ATTACHMENT A SUMMARY OF COBRA PROCEDURES It is BASIC s policy to do all we can to make COBRA worry-free. However, there are certain steps the employer is required to do: 1. Notify COBRA Recordkeeper of Initial Events (new additions to the health plan). 2. Notify COBRA Recordkeeper of Qualifying Events within 30 days of event. The qualifying events are: a. Termination of Employment (voluntary or involuntary) b. Reduction of Work Hours c. Employee s Death d. Divorce or Legal Separation e. Loss of Dependent Status f. Medicare Entitlement g. Bankruptcy of Employer 3. Notify COBRA Recordkeeper of Unavailability of COBRA Event 4. Notify Insurance providers of additions and terminations 5. Notify COBRA Recordkeeper of discrepancies in the monthly summary reports 6. Notify COBRA Recordkeeper of insurance renewal rates and additions/changes of COBRA qualified benefits. Initial Notifications: Employer must notify COBRA Recordkeeper if an employee enrolls on the group benefits such as medical, dental, vision and or medical reimbursement. You will report this information at our secure web site at COBRA Recordkeeper will process the initial notifications. The letter will be mailed to the employee s home address. COBRA Recordkeeper will archive all records. This information will be reported on the monthly Initial Notification report sent to the employer. Qualifying Event Notification: Employer must notify COBRA Recordkeeper of all Qualifying Events as listed above in item 2. You will report this information at our secure web site at COBRA Recordkeeper will process the qualifying event notifications. The following information will be sent: COBRA Qualifying Event letter, election form including the rates and the HIPAA Certificate of Coverage. The letter will be mailed to the employee s home address via certificate of mailing. COBRA Recordkeeper will archive all records. This information will be reported on the monthly Qualifying Event Notification report sent to the employer. COBRA Summary and Election Process COBRA Recordkeeper will process the election form and notify the employer via . COBRA Recordkeeper will advise the employer of the election made and if any premiums have been 8

19 submitted. Please remember it is the responsibility of the employer to put the Qualified Beneficiary back on the appropriate health plan according to the election made. COBRA Recordkeeper will send out monthly payment coupons to the qualified beneficiaries for their use in remitting the monthly premium payments. Premium Collections COBRA participants will make their monthly premium payment to COBRA Recordkeeper. COBRA Recordkeeper will keep the 2% administrative fee and return monthly premium to employer. Termination of COBRA COBRA Recordkeeper will notify the client on a weekly basis if any COBRA terminations occur. This could be for non-payment of monthly COBRA premiums, voluntary termination or end of COBRA time frame. Please be advised it is the responsibility of the employer to terminate the COBRA participant off the plans in which they are covered. The termination information will appear on the monthly Termination Report. Insurance Renewal Rates COBRA Recordkeeper will advise the employer 30 days prior to the insurance plan rate changes. It is the responsibility of the employer to provide COBRA Recordkeeper with the new rates. If there is a change in the health/dental carrier, please fill out a new Insurance Company Information form. This form is filled out via our web site It is very imperative that COBRA Recordkeeper receives the new rate information. If the rates are not received, this will delay the daily processing of all initial notifications, qualifying event notices and posting of monthly premium payments. On Going COBRA Administration Service COBRA Recordkeeper will continue to send payment coupons to the COBRA participants, post payment to the accounts and notify the employer on monthly reports. COBRA Recordkeeper will issue multiple COBRA event letters at no additional charge and send out conversion notifications if applicable. COBRA Recordkeeper will notify the COBRA participant of rate renewal changes. They will receive a letter of change along with additional payment coupons. Open Enrollment The employer is responsible for sending out a renewal packet to the COBRA participants. The employer must notify COBRA Recordkeeper of any changes that the COBRA participant has made. 9

20 FEE SCHEDULE Employer, Agent or BASIC can write in predetermined fee schedule in box below. One Time Setup Fee Per Insured Monthly Fee (Monthly Minimum $ ) Events prior to Contract Effective Date: $4.25 per Initial Notices $30.00 per COBRA Takeover Qualifying Events in excess of 20% of insured employees: $15.00 each Additional fees that may apply: EDI Files: Set-up fee of $250 for each line of service to establish secure file transmissions, consult on format requirements, and test files. Monthly fees only apply if files are not provided in BASIC's format, missing data, inaccurate data, or transmitted in a non-standard manner. The monthly fee will be assessed on a case by case basis. Open Enrollment Packets and/or SBC Notifications (typically $15 per packet based on amount of material received and postage) to COBRA participants. Contact BASIC for more information. BASIC has the right to apply additional fees for any service outside the scope of its contracted services. EMPLOYER TO INITIAL WITH ACCEPTANCE OF FEES HERE 10

21 BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement, is entered into as of, by and between Health Plan (the Plan or Covered Entity ); and Benefit Administration Services International Corporation (the "Business Associate"). WITNESSETH: WHEREAS, the Covered Entity previously has entered into an agreement (the Agreement ) with the Business Associate, whereby the Business Associate has agreed to provide certain services to the Plan; WHEREAS, to provide such services to the Plan, the Business Associate must have access to certain protected health information ("Protected Health Information" or "PHI"), as defined in the Standards for Privacy of Individually Identifiable Health Information (the "Privacy Standards") set forth by the U.S. Department of Health and Human Services ( HHS ) pursuant to the Health Insurance Portability and Accountability Act of 1996, ("HIPAA") and amended by the Health Information Technology for Economic and Clinical Health Act ( HITECH Act ), part of the American Recovery and Reinvestment Act of 2009 ( ARRA ), the Genetic Information Nondiscrimination Act of 2008 ( GINA ), and the final regulations to such Acts promulgated in January 2013; WHEREAS, to comply with the requirements of the Privacy Standards, the Covered Entity must enter into this Business Associate Agreement with the Business Associate. NOW, THEREFORE, in consideration of the mutual covenants and agreements hereinafter contained, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, and intending to be legally bound hereby, the parties hereto agree as follows: I. Definitions The following terms used in this Agreement shall have the same meaning as those terms in the Privacy Rules: Breach, Data Aggregation, Designated Record Set, Disclosure, Health Care Operations, Individual, Minimum Necessary, Notice of Privacy Practices, Secretary, Subcontractor, and Use. If other terms are used, but not otherwise defined under this Business Associate Agreement, such terms shall then have the same meaning as those terms in the Privacy Rule. (a) Business Associate. Business Associate shall generally have the same meaning as the term business associate at 45 CFR (b) Covered Electronic Transactions. Covered Electronic Transactions shall have the meaning given the term transaction in 45 CFR (c) Covered Entity. Covered Entity shall generally have the same meaning as the term covered entity at 45 CFR (d) Electronic Protected Health Information. Electronic Protected Health Information shall have the same meaning as the term electronic protected health information in 45 CFR (e) Genetic Information. Genetic Information shall have the same meaning as the term genetic information in 45 CFR (f) HIPAA Rules. HIPAA Rules shall mean the Privacy, Security, Breach Notification, and Enforcement Rules at 45 CFR Part 160 and Part 164. (g) Individual. Individual shall have the same meaning as the term individual in 45 CFR and shall include a person who qualifies as a personal representative in accordance with 45 CFR (g). (h) Privacy Rule. Privacy Rule shall mean the Standards for Privacy of Individually Identifiable Health Information at 45 CFR Part 160 and Part 164, subparts A and E.

22 (i) Protected Health Information (PHI). Protected Health Information (PHI) shall have the same meaning as the term protected health information in 45 CFR , limited to the information created or received by Business Associate from or on behalf of a Covered Entity pursuant to this Agreement. (j) Required By Law. Required By Law shall have the same meaning as the term required by law in 45 CFR (k) Secretary. Secretary shall mean the Secretary of the Department of Health and Human Services or his designee. (l) Standards for Electronic Transactions Rule. Standards for Electronic Transactions Rule means the final regulations issued by HHS concerning standard transactions and code sets under the Administration Simplification provisions of HIPAA, 45 CFR Part 160 and Part 162. (m) Security Incident. Security Incident shall have the same meaning as the term security incident in 45 CFR (n) Security Rule. Security Rule shall mean the Security Standards and Implementation Specifications at 45 CFR Part 160 and Part 164, subpart C. (o) Subcontractor. Subcontractor shall have the same meaning as the term subcontractor in 45 CFR (p) Transaction. Transaction shall have the meaning given the term transaction in 45 CFR (q) Unsecured Protected Health Information. Unsecured Protected Health Information shall have the meaning given the term unsecured protected health information in 45 CFR II. Safeguarding Privacy and Security of Protected Health Information (a) Permitted Uses and Disclosures. The Business Associate is permitted to use and disclose Protected Health Information that it creates or receives on the Covered Entity s behalf or receives from the Covered Entity (or another business associate of the Covered Entity) and to request Protected Health Information on the Covered Entity s behalf (collectively, Covered Entity s Protected Health Information ) only: (i) Functions and Activities on the Covered Entity s Behalf. To perform those services referred in the attached services agreement. (ii) Business Associate s Operations. For the Business Associate s proper management and administration or to carry out the Business Associate s legal responsibilities, provided that, with respect to disclosure of the Covered Entity s Protected Health Information, either: (A) The disclosure is Required by Law; or (B) The Business Associate obtains reasonable assurance from any person or entity to which the Business Associate will disclose the Covered Entity s Protected Health Information that the person or entity will: (1) Hold the Covered Entity s Protected Health Information in confidence and use or further disclose the Covered Entity s Protected Health Information only for the purpose for which the Business Associate disclosed the Covered Entity s Protected Health Information to the person or entity or as Required by Law; and (2) Promptly notify the Business Associate (who will in turn notify the Covered Entity in accordance with the breach notification provisions) of any instance of which the person or entity becomes aware in which the confidentiality of the Covered Entity s Protected Health Information was breached. (C) To de-identify the information in accordance with 45 CFR (a) (c) as necessary to perform those services required under the Agreement. 2

23 (iii) Minimum Necessary. The Business Associate will, in its performance of the functions, activities, services, and operations specified above, make reasonable efforts to use, to disclose, and to request only the minimum amount of the Covered Entity s Protected Health Information reasonably necessary to accomplish the intended purpose of the use, disclosure or request, except that the Business Associate will not be obligated to comply with this minimum-necessary limitation if neither the Business Associate nor the Covered Entity is required to limit its use, disclosure or request to the minimum necessary. The Business Associate and the Covered Entity acknowledge that the phrase minimum necessary shall be interpreted in accordance with the HITECH Act. (b) Prohibition on Unauthorized Use or Disclosure. The Business Associate will neither use nor disclose the Covered Entity s Protected Health Information, except as permitted or required by this Agreement or in writing by the Covered Entity or as Required by Law. This Agreement does not authorize the Business Associate to use or disclose the Covered Entity s Protected Health Information in a manner that will violate Subpart E of 45 CFR Part 164 if done by the Covered Entity. (c) Information Safeguards. (i) Privacy of the Covered Entity s Protected Health Information. The Business Associate will develop, implement, maintain, and use appropriate administrative, technical, and physical safeguards to protect the privacy of the Covered Entity s Protected Health Information. The safeguards must reasonably protect the Covered Entity s Protected Health Information from any intentional or unintentional use or disclosure in violation of the Privacy Rule and limit incidental uses or disclosures made to a use or disclosure otherwise permitted by this Agreement. (ii) Security of the Covered Entity s Electronic Protected Health Information. The Business Associate will develop, implement, maintain, and use administrative, technical, and physical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of Electronic Protected Health Information that the Business Associate creates, receives, maintains, or transmits on the Covered Entity s behalf as required by the Security Rule. The Business Associate with comply with Subpart C of 45 CFR Part 164 with respect to Electronic Protected Health Information, to prevent use or disclosure of protected health information other than as provided for by the Agreement. (iii) No Transfer of PHI Outside United States. Business Associate will not transfer Protected Health Information outside the United States without the prior written consent of the Covered Entity. In this context, a transfer outside the United States occurs if Business Associate's workforce members, agents, or subcontractors physically located outside the United States are able to access, use, or disclose Protected Health Information. (iv) Policies and Procedures. The Business Associate shall maintain written policies and procedures, conduct a risk analysis, and train and discipline of its workforce. (d) Subcontractors and Agents. In accordance with 45 CFR (e)(1)(ii) and (b)(2), if applicable, the Business Associate will ensure that any of its Subcontractors and agents that create, receive, maintain, or transmit Protected Health information on behalf of the Business Associate agree to the same restrictions, conditions, and requirements that apply to the Business Associate with respect to such information. (e) Prohibition on Sale of Records. As of the effective date specified by HHS in final regulations to be issued on this topic, the Business Associate shall not directly or indirectly receive remuneration in exchange for any Protected Health Information of an individual unless the Covered Entity or Business Associate obtained from the individual, in accordance with 45 CFR , a valid authorization that includes a specification of whether the Protected Health Information can be further exchanged for remuneration by the entity receiving Protected Health Information of that individual, except as otherwise allowed under the HITECH Act. (f) Prohibition on Use or Disclosure of Genetic Information. Business Associate shall not use or disclose Genetic Information for underwriting purposes in violation of the HIPAA rules. (g) Penalties For Noncompliance. The Business Associate acknowledges that it is subject to civil and criminal enforcement for failure to comply with the privacy rule and security rule under the HIPAA Rules, as amended by the HITECH Act. 3

24 III. Compliance with Electronic Transactions Rule If the Business Associate conducts in whole or part Electronic Transactions on behalf of the Covered Entity for which HHS has established standards, the Business Associate will comply, and will require any Subcontractor or agent it involves with the conduct of such Transactions to comply, with each applicable requirement of the Electronic Transactions Rule. The Business Associate shall also comply with the National Provider Identifier requirements, if and to the extent applicable. IV. Obligations of the Covered Entity The Covered Entity shall notify the Business Associate of: (a) Any limitation(s) in its notice of privacy practices of the Covered Entity in accordance with 45 CFR , to the extent that such limitation may affect the Business Associate s use or disclosure of Protected Health Information; (b) Any changes in, or revocation of, permission by the Individual to use or disclose Protected Health Information, to the extent that such changes may affect the Business Associate s use or disclosure of Protected Health Information; and (c) Any restriction to the use or disclosure of Protected Health Information that the Covered Entity has agreed to in accordance with 45 CFR , to the extent that such restriction may affect the Business Associate s use or disclosure of Protected Health Information. V. Permissible Requests by the Covered Entity The Covered Entity shall not request the Business Associate to use or disclose Protected Health Information in any manner that would not be permissible under the Privacy Rule if done by the Covered Entity. VI. Individual Rights (a) Access. The Business Associate will, within twenty-five (25) calendar days following the Covered Entity s request, make available to the Covered Entity or, at the Covered Entity s direction, to an individual (or the individual s personal representative) for inspection and obtaining copies of the Covered Entity s Protected Health Information about the individual that is in the Business Associate s custody or control, so that the Covered Entity may meet its access obligations under 45 CFR Effective as of the date specified by HHS, if the Protected Health Information is held electronically in a designated record Set in the Business Associate s custody or control, Business Associate will provide an electronic copy in the form and format specified by the Covered Entity if it is readily producible in such form. The Business Associate will provide an electronic copy in the form and format specified by the Covered Entity if it is readily producible in such format; if it is not readily producible in such format, the Business Associate will work with the Covered Entity to determine an alternative form and format as specified by the Covered Entity to meet its electronic access obligations under 45 CFR (b) Amendment. The Business Associate will, upon receipt of written notice from the Covered Entity, promptly amend or permit the Covered Entity access to amend any portion of the Covered Entity s Protected Health Information in a designated record set as directed or agreed to by the Covered Entity, so that the Covered Entity may meet its amendment obligations under 45 CFR (c) Disclosure Accounting. The Business Associate will maintain and make available the information required to provide an accounting of disclosures to the Covered Entity as necessary to satisfy the Covered Entity s obligations under 45 CFR (i) Disclosures Subject to Accounting. The Business Associate will record the information specified below ( Disclosure Information ) for each disclosure of the Covered Entity s Protected Health Information, not excepted from disclosure accounting as specified below, that the Business Associate makes to the Covered Entity or to a third party. (ii) Disclosures Not Subject to Accounting. The Business Associate will not be obligated to record Disclosure Information or otherwise account for disclosures of the Covered Entity s Protected Health Information if the Covered Entity need not account for such disclosures under the HIPAA Rules. 4