WASHINGTON ALLIANCE FOR HEALTHCARE INSURANCE TRUST

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1 WASHINGTON ALLIANCE FOR HEALTHCARE INSURANCE TRUST administered by Benefit Solutions, Inc th Street, SW Suite 601 Lynnwood, WA phone fax Locator # W/ Effective Date: IMPORTANT NOTICE TO: FROM: RE: Employers Responsible for COBRA* Continuation Administration in the Washington Alliance for Healthcare Insurance Trust. Benefit Solutions, Inc. COBRA Department, Administrative Office COBRA Administration It is important that each employer be aware of their responsibility with regard to the COBRA requirements. Generally, any employer who retains more than twenty employees is obligated to offer COBRA rights to their employees. There are other unique employer scenarios which also require COBRA compliance. If there is any doubt as to whether or not your company is required to comply with the COBRA regulations, you are encouraged to seek legal counsel. As a service provided to participating WAHIT employers, Benefit Solutions, Inc. is prepared to assume the administrative functions of COBRA notification and billings for your eligible COBRA employees at no extra charge. Attached is an agreement which you will need to review and sign if you desire to take advantage of the services. G YES, we wish to use the services of Benefit Solutions, Inc. for COBRA administration and hereby enclose the signed agreement. G NO, we do not want to use the services of Benefit Solutions, Inc. for COBRA administration and we understand that we will maintain our own COBRA procedures and policies with regard to terminated employees. If you have checked YES above, please complete and sign the attached COBRA Administration Agreement and return to our office as soon as possible. If you currently have Employees on COBRA, please complete an Employer Request for Employee Termination/and Employee Continuation of Coverage form for each Employee on Cobra. (One of these forms should be completed and forwarded to us for each Employee who elects COBRA in the future.) It is very important that we receive a response from each Employer so that our records are accurate. If an employer does not respond, it will be assumed that any COBRA administration that may be necessary is being handled by the Employer. *Consolidated Omnibus Budget Reconciliation Act of 1986

2 COBRA ADMINISTRATION AGREEMENT WHEREAS,, hereinafter referred to as the "Employer," has determined it wishes to engage the services of Benefit Solutions, Inc. hereinafter referred to as "," in order to comply with the requirements of the Consolidated Omnibus Budget Reconciliation Act of 1986, as amended from time to time ("COBRA"), as the same relates to the mandatory continuation coverage of health benefits as supplied by Employer to participants in its employee welfare benefit plan; WHEREAS, in furtherance Employer's determination to comply with the requirements of COBRA, Employer desires to delegate certain ministerial functions and authority to with regard to record keeping and accounting of qualified beneficiaries whose benefits have become terminated and who are entitled to continuation coverage under COBRA; WHEREAS, Employer is a participating Employer in the Washington Alliance for Health Insurance Trust and this Agreement is entered into in connection with the administration of Employer's employee benefit plan under the Washington Alliance for Health Insurance Trust; NOW, THEREFORE, in consideration of the mutual covenants, conditions and agreements as hereinafter set forth, the Employer and do hereby agree as follows: ARTICLE I Definitions 1.1 Unless otherwise defined herein, capitalized terms used herein have the same meaning as ascribed to them in the Agreement. 1.2 The term "Continuation Coverage" shall mean the extended health care coverage required by COBRA. 1.3 The term "Qualified Beneficiaries" shall mean those individuals who have experienced a "Qualifying Event" as defined by COBRA and who have elected Continuation Coverage under the Plan. 1.4 The term "Monthly Contribution Amount" means the amount the Qualified Beneficiary must contribute for Continuation Coverage. ARTICLE II Responsibilities of Employer 2.1 During the term of this Agreement, Employer will: (a) Provide eligibility information to. The Employer will notify of persons who have experienced a Qualifying Event within 30 days of the Qualifying Event. The notification will be 1

3 by noting termination or other changes of employment status on the monthly employer report, or by separate notification to. The information provided in the notification will include the following: Name, Social Security Number Date and Type of Qualifying Event 3.1 During the term of this Agreement, will: ARTICLE III Responsibilities or (a) (b) (c) provide standard COBRA election forms to Qualified Beneficiaries; bill Qualified Beneficiaries for the monthly contribution amounts; and collect and remit monthly contribution amounts from Qualified Beneficiaries. 3.2 will provide notification of the right to elect continuation coverage under the Employer's plan to persons who have been identified to by the Employer as having experienced a Qualifying Event. The notice will be mailed by first class mail to such persons at the mailing address provided to by the Employer. The notice will be mailed within fourteen (14) calendar days from receipt of the notification from the Employer. The notice will specify the plan(s) for which the Qualified Beneficiary is eligible and the premium rate and due date. 3.3 Unless otherwise notified in writing, will be entitled to conclusively presume that a Qualified Beneficiary's eligibility for continuation of coverage under the Employer's Plan has not terminated by reason of coverage under another group health plan or by becoming eligible for Medicare. 3.4 It is expressly understood that will not be the Plan Administrator or "Named Fiduciary" with respect to the Employer's Plan as those terms are defined by ERISA or the Internal Revenue Code as the result of this Agreement. ARTICLE IV Fees 4.1 will not charge the Employer a separate fee for the services described in this Agreement. ARTICLE V Indemnification 5.1 Employer agrees to indemnify and hold harmless against any loss, damage, or expense, including reasonable attorney 5 fees that may incur or be required to pay as a result of any claim, demand, cause of action, lawsuit or proceeding arising out of or in any way in connection with the services provided under this Agreement unless it is determined in a final judgement of a court competent jurisdiction that such loss, damage or expense was the result of 's willful 2

4 misconduct or neglect, fraud or bad faith. Employer agrees to indemnify and hold harmless against any penalty which is or will be imposed upon it under ERISA and pertinent regulations thereunder or the imposition of an excise tax upon under Section 4980B of the Internal Revenue Code or any other penalties which may be imposed by law or regulation in connection with COBRA, unless it is determined that the liability therefore was the direct consequence of the dishonest, fraudulent or criminal acts of or its employees. ARTICLE VI Notices 6.1 Any notices permitted or required by this Agreement shall be delivered in person to the intended recipient, or shall be sent to such person by first class mail or prepaid telegram at his or her last known address. ARTICLE VII Severability 7.1 If any term or provision of this Agreement is held to be unlawful or invalid for any reason, such unlawfulness or invalidity shall not affect the remaining portions of this Agreement. ARTICLE VIII Construction 8.1 This Agreement shall be construed and interpreted in accordance with the laws of the State of Washington, the Employee Retirement Income Security Act of 1974, the Internal Revenue Code and the regulations thereunder, and any other applicable federal and state statutes and regulations. ARTICLE IX Arbitration of Disputes 9.1 Any claim or controversy that arises out of or relates to this Agreement or breach of it will be settled by arbitration in the City of Seattle, in the State of Washington, in accordance with the rules then obtaining of the American Arbitration Association. Judgment upon the award rendered may be entered in the King County Superior Court in the State of Washington. Benefit Solutions, Inc. Name of Employer By: By: 3

5 Title: Date: Title: Date: Please do not write below this line For administrative use only Copy of accepted agreement returned to Employer on by 4

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