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PSF_ SHARED FUNDING Administration

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					                                                EMPLOYEE BENEFIT SYSTEMS
        Partial Self Funded          Dental                 Vision          COBRA               Billing
         New Group
         Renewal Group                                                                   EBS System Data
                                                                                             Client Number:
                                                                                             Effective Date:
  Plan Year:

A) Plan Sponsor - All information is required for New & Renewal Group
         Group:                                                                                     Tax ID:
       Address:
                                                                           City                   State         Zip

    Telephone:                                     Facsimile:                                      Website:
       Contact:                                           Title:                                       Email:
  Position Title(s) that manages HIPAA/PHI:
    Broker Name & Agency:                                                                       Telephone:
  Address:                                                                                   E-mail:



B) Banking & Billing Information - All information is required for New & Renewal Group
  Banking Information:
  Client shall adequately fund a checking account, which shall be used for maintaining reserve funds, payment of Client's
  claims, premiums and monthly administration fee and other approved expenses. Client will be responsible for any monthly
  checking account service charges relating to this account.

  Option 1
      Employer Bank Account -
  Employer maintains own bank account. As claims and checks are processed employer will be notified via electronic check
  register. It is the responsibility of the employer to maintain adequate funding of the account. EBS will not hold checks.
  (Complete signature form)
  Bank name:
  Address or telephone:
  ABA routing number:
  Account number:

  Option 2
      EBS Bank Account - Please select one of the options below:


     Fund as Claims Processed - EBS will setup an internal bank account. Initial deposit of $25 is required to hold account
   open. Claim payments whether by check or ACH will be processed by EBS and notification will be sent to the employer.
   Payment will be withdrawn via ACH directly from employers bank account each time claims are processed.
  (Complete ACH Form)
     Fund as Client Billed -      EBS will setup an internal bank account. Initial deposit of $25 is required to hold account
   open. Claim payments whether by check or ACH will be processed by EBS and notification will be sent to the employer.
  Funds are collected via a monthly bill sent to the employer. If additional funding is needed or funds are not available
   employer will be notified and an ACH deposit will be required prior to the claims being released. (Complete ACH Form)


  Billing Information:
  Is EBS providing billing payment services?:               Yes      No
  Does the agent want a copy of month end report?                    Yes     No
             Medical                                                 Vendor:
             Dental                                                  Vendor:
             Vision                                                  Vendor:
             Group Life/ LTD/ AD&D                                   Vendor:
             Other                                                   Vendor:
    Will ID cards be issued?:         Yes            No




   Revised 5/15/2009                                                                                                            1
                                                EMPLOYEE BENEFIT SYSTEMS
C) Census, Plan Documentation, Claim Data - All information is required for New & Renewal Group

  Is the group currently Partial Self Funding?:          Yes       No
            Census for new group setup employee and dependent
            Current medical insurance carrier                                                                  Comments
            Current dental insurance carrier
            Current vision insurance carrier
            Current administrator/TPA
            Master policy, plan document (EBS general benefit document will be used if none is provided)
                  electronic or written:
           Summary plan of benefits
                  electronic or written:
        Name & title of person authorized to make Plan Document revisions:
            4th quarter carryover credit         Yes       No
            If EBS pays run-out claims, previous year accumulator reports required (deductible & OPM)
           Who will be responsible for claims "run-out"?:            EBS          Prior Carrier
  How often are claims to be processed:


D) Contracts & Fees - All information is required for New & Renewal Group
            Signed Administrative Agreement
            Signed Business Associate Agreement
            Signed PHI Release from primary plan
            Signed Health Plan Authorized Representative Designation

                                                                                              Fees:
                Total Eligible:                                   PSF Admin                 COBRA Admin
                Participant #:                                 Billing Admin                            EOB        (electronic admission fee)

                       Setup Fee:                              Dental Admin                       Broker fee
                                                                Vision Admin                      Total Fees
  * Pop Plan included for no extra charge.




   Revised 5/15/2009                                                                                                                    2
                                                EMPLOYEE BENEFIT SYSTEMS
E) Group Plan Definition - All information is required for New & Renewal Group

  PRIMARY PLAN (WHAT THE EMPLOYER BUYS)
       Carrier:                                         In-Network                                       Non-Network
                                                    Single         Family                        Single           Family
                                  Deductible:
                  Out-of-pocket maximum:
                                Coinsurance:
        Is the deductible included in OPM:
                                                        Yes             No                         Yes             No
        Copay: OV =                             ER =                             Wellness =$                 Supl Accd = $
        Drug program:


  REIMBURSEMENT PLAN (WHAT THE EMPLOYEE IS OFFERED)
     If there is more than 1 plan, remember to include additional plans on an additional sheet
                                                        In-Network                                       Non-Network
                                                    Single         Family                        Single           Family
                                  Deductible:
                  Out-of-pocket maximum:
                                Coinsurance:
        Is the deductible included in OPM:               Yes             No                         Yes                No
       Copay : OV=                              ER =                             Wellness =$                 Supl Accd = $
        Drug program:


 Maximum dollar exposure to the employer per member, in-network:
 Maximum dollar exposure to the employer per member, non-network:
 When does a new employee come on to the plan?                    (ex. 1st of month following 90 days)
 When does an employee term from the plan?                        (ex.1st of the following month)

 Comments:


 I have read the setup documentation and agree it is correct and setup as I directed.


 Signature:                                                                           Date:




   Revised 5/15/2009                                                                                                         3

				
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