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Our Cost Plus Agreement Alternative Benefit Solutions

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Our Cost Plus Agreement Alternative Benefit Solutions Powered By Docstoc
					                                                                                                                           Broker	
  Contact	
  Name:	
  _________________________	
  
                                                                                                                                                     Alternative Benefit Solutions
                                                                                                                                           P.O. Box 31015 • Barrie, ON • L4N 0B3
                                                                                                                Phone 705.726.6100 • Toll Free 1.866.636.8359 • Fax 705.726.9090

                                                                                                                                A proud subsidiary of GroupHEALTH Global Benefit Systems Inc.



                                                                    Our	
  CostPlus	
  AGREEMENT	
  
	
  
THIS	
  AGREEMENT	
  is	
  dated	
  for	
  reference	
                                                                                                                                           	
  

BETWEEN:	
                 Alternative	
  Benefit	
  Solutions	
  
                                                                                                  OF	
  THE	
  FIRST	
  PART	
  
                                                                                                                            	
  
AND:	
       	
            ________________________________________________________________________________	
               	
  
                           (hereinafter	
  referred	
  to	
  as	
  “the	
  Employer”)	
  
                                                                                                                                                              OF	
  THE	
  SECOND	
  PART	
  

NOW	
  THEREFORE	
  THIS	
  AGREEMENT	
  WITNESSETH	
  THAT	
  in	
  consideration	
  of	
  the	
  premises	
  and	
  the	
  mutual	
  covenants	
  and	
  
agreements	
  hereinafter	
  contained,	
  the	
  parties	
  hereto	
  agree	
  as	
  follows:	
  

Section	
  I.	
  	
  General	
  Provisions	
  
1.     It	
  is	
  understood	
  that	
  the	
  Employer	
  retains	
  all	
  final	
  authority	
  and	
  responsibility	
  for	
  the	
  Plan	
  and	
  its	
  operations	
  and	
  that	
  
       Alternative	
  Benefit	
  Solutions	
  is	
  empowered	
  to	
  act	
  on	
  behalf	
  of	
  the	
  Employer	
  in	
  connection	
  with	
  the	
  Plan	
  only	
  as	
  
       expressly	
  stated	
  in	
  this	
  Agreement	
  or	
  as	
  mutually	
  agreed	
  to	
  in	
  writing	
  by	
  the	
  Employer	
  and	
  Alternative	
  Benefit	
  
       Solutions.	
  
2.     The	
  Employer	
  agrees	
  to	
  hold	
  Alternative	
  Benefit	
  Solutions	
  and	
  its	
  employees	
  harmless	
  from	
  any	
  and	
  all	
  claims,	
  lawsuits,	
  
       judgments,	
  costs,	
  penalties	
  and	
  expenses,	
  including	
  attorney’s	
  fees	
  resulting	
  from,	
  or	
  arising	
  out	
  of	
  or	
  in	
  connection	
  
       with	
  any	
  function	
  of	
  Alternative	
  Benefit	
  Solutions	
  under	
  the	
  Agreement,	
  unless	
  it	
  is	
  determined	
  that	
  the	
  liability	
  thereof	
  
       was	
  the	
  direct	
  or	
  indirect	
  consequence	
  of	
  criminal	
  conduct,	
  gross	
  negligence	
  or	
  fraud	
  on	
  the	
  part	
  of	
  Alternative	
  Benefit	
  
       Solutions	
  or	
  any	
  of	
  its	
  employees	
  
	
  
Section	
  II.	
  	
  Obligations	
  of	
  the	
  Employer	
  
1.     The	
  Employer	
  shall	
  have	
  the	
  obligation:	
  
             (a)           to	
  furnish	
  all	
  claims,	
  including	
  original	
  receipts,	
  on	
  the	
  prescribed	
  Cost	
  Plus	
  Preferred	
  Claim	
  Form	
  
                           furnished	
  by	
  Alternative	
  Benefit	
  Solutions.	
  
             (b)           to	
  provide	
  with	
  said	
  claim	
  form	
  a	
  cheque	
  for	
  the	
  Total	
  Amount	
  Payable	
  as	
  calculated	
  on	
  said	
  claim	
  form.	
  
             (c)           to	
  verify	
  that	
  the	
  employee	
  named	
  on	
  the	
  claim	
  form	
  is	
  eligible	
  for	
  payment	
  under	
  the	
  Plan.	
  

2.     The	
  Employer	
  will	
  provide	
  Alternative	
  Benefit	
  Solutions	
  with	
  the	
  name(s)	
  of	
  individual(s)	
  authorized	
  to	
  act	
  for	
  the	
  
       Employer	
  in	
  connection	
  with	
  this	
  agreement.	
  

3.     The	
  Employer	
  will	
  be	
  responsible	
  for	
  any	
  Provincial	
  or	
  Federal	
  taxes	
  payable	
  with	
  respect	
  to	
  any	
  claims	
  processed.	
  

4.     There	
  may	
  be	
  tax	
  implications	
  for	
  benefits	
  paid	
  to	
  an	
  owner/principal	
  shareholder	
  and	
  their	
  dependents.	
  Alternative	
  
       Benefit	
  Solutions	
  suggests	
  that	
  the	
  Employer	
  contact	
  Canada	
  Revenue	
  Agency	
  for	
  details.	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  


                                                                                     Page	
  1	
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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Alternative Benefit Solutions
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     P.O. Box 31015 • Barrie, ON • L4N 0B3
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Phone 705.726.6100 • Toll Free 1.866.636.8359 • Fax 705.726.9090

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 A proud subsidiary of GroupHEALTH Global Benefit Systems Inc.



	
  
Section	
  III.	
  	
  Employer	
  Address	
  and	
  Contact	
  
       ________________________________________________ 	
                                                                                                                                                                                                                                                                                                                                                                                                           _________________________________________________ 	
  
	
                                                                                                                                                                                                                                             Address	
                                                                                                                                                                                                                                                                                                   Administrator	
  Contact	
  Name	
  
    ____________________________________________________________ 	
   _______________________________________________________________	
  
	
   City	
                        Province	
         Postal	
  Code	
   	
  	
  Phone	
  Number	
   Email	
  Address	
  
	
  
SECTION	
  IV.	
  	
  Obligations	
  of	
  Alternative	
  Benefit	
  Solutions	
  
1.                                     Alternative	
  Benefit	
  Solutions	
  will	
  maintain	
  records	
  of	
  each	
  claim	
  and	
  payment	
  made	
  thereof.	
  

2.                                     With	
  each	
  claim	
  Alternative	
  Benefit	
  Solutions	
  will	
  verify	
  that	
  the	
  expenses	
  are	
  eligible	
  for	
  reimbursement	
  under	
  the	
  
                                       plan.	
  

3.                                     Alternative	
  Benefit	
  Solutions	
  will	
  charge	
  a	
  fee	
  for	
  claims	
  processing	
  of	
  10%	
  of	
  the	
  total	
  of	
  the	
  claim	
  amount,	
  with	
  a	
  
                                       minimum	
  of	
  $50.00	
  per	
  claim,	
  plus	
  applicable	
  taxes.	
  

4.                                     Alternative	
  Benefit	
  Solutions	
  will	
  refer	
  any	
  problems	
  regarding	
  the	
  claim	
  to	
  the	
  Employer.	
  

5.                                     Alternative	
  Benefit	
  Solutions	
  will	
  provide	
  details	
  of	
  the	
  claim	
  with	
  each	
  cheque	
  and	
  that	
  will	
  be	
  the	
  sole	
  record	
  issued.	
  
	
  
6.                                     Alternative	
  Benefit	
  Solutions	
  will	
  guarantee	
  a	
  five	
  business	
  day	
  return	
  on	
  the	
  Cost	
  Plus	
  Preferred	
  claim	
  if	
  paid	
  by	
  
                                       cheque.	
  As	
  an	
  alternative,	
  Alternative	
  Benefit	
  Solutions	
  can	
  guarantee	
  a	
  48	
  hour	
  return	
  of	
  payment	
  to	
  the	
  employee	
  if	
  
                                       the	
  employer	
  chooses	
  a	
  pre	
  authorized	
  Debit	
  withdrawal	
  as	
  a	
  method	
  of	
  payment	
  for	
  the	
  Cost	
  Plus	
  Preferred	
  claim.	
  	
  
                                       Employer:	
  Bank	
  Code	
  _____________	
  Transit	
  #	
  _____________	
  Account	
  #	
  	
  ____________________	
  
                                                                                                                                                                                                                                                                                         3	
  digits	
                                                                                                                                             5	
  digits	
  
7.                                     Claims	
  received	
  without	
  an	
  accompanying	
  cheque	
  or	
  authorized	
  signature	
  will	
  be	
  returned	
  to	
  the	
  Employer.	
  All	
  claims	
  
                                       and	
  payments	
  should	
  be	
  forwarded	
  directly	
  to	
  Alternative	
  Benefit	
  Solutions	
  Claims	
  Centre.	
  	
  
	
  
Section	
  V.	
  	
  Termination	
  of	
  Services	
  

1.                                     Either	
  party	
  may	
  terminate	
  this	
  agreement	
  with	
  30	
  days	
  prior	
  written	
  notice	
  to	
  the	
  other.	
  	
  All	
  claims	
  submitted	
  after	
  
                                       the	
  termination	
  date	
  of	
  this	
  agreement	
  will	
  be	
  returned	
  to	
  the	
  Employer.	
  
	
  
Section	
  VI.	
  	
  
	
  
IN	
  WITNESS	
  WHEREOF,	
  Alternative	
  Benefit	
  Solutions	
  and	
  the	
  Employer	
  have	
  caused	
  the	
  agreement	
  to	
  be	
  executed	
  in	
  
duplicate	
  by	
  their	
  respective	
  duly	
  authorized	
  officers.	
  
	
  
	
  Alternative	
  Benefit	
  Solutions	
  	
                                      EMPLOYER__________________________________________________	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
                     	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Full	
  Legal	
  Name	
  of	
  the	
  Employer	
  

       ____________________________________________________________ 	
                                                                                                                                                                                                                                                                                                                                                                                         _______________________________________________________________	
  
                            Authorized	
  Signature	
                                                                                                                                                                                                                                                                                                                                                                                                                                 	
  Authorized	
  Signature	
  

       ____________________________________________________________ 	
                                                                                                                                                                                                                                                                                                                                                                                         _______________________________________________________________	
  
	
                                 Name	
                                                                                                                                                                                                                                                                                                                                                                                                                                                   Name	
  

       ____________________________________________________________ 	
                                                                                                                                                                                                                                                                                                                                                                                         _______________________________________________________________	
  
	
                                 Title	
                                                                                                                                                                                                                                                                                                                                                                                                                                                   Title	
  
       ____________________________________________________________ 	
                                                                                                                                                                                                                                                                                                                                                                                         _______________________________________________________________	
  
	
                                 Date	
                                                                                                                                                                                                                                                                                                                                                                                                                                                   Date	
   	
  	
  	
  	
  	
  	
  	
  	
  	
  




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