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					                    MEMORANDUM OF AGREEMENT
                                Between
                          INFINISOURCE, INC.
                                  And
________________________________________________________________________
                            Legal Name of Employer/Plan Administrator (ER/PA)

Infinisource Account Number:____________________________

Regarding: COBRA General Notice Mailing for Current Insured Employee’s

In contracting with Infinisource, Inc. (hereinafter Infinisource), the issue of providing current insured,
possible electees, electees, and Continuees of the ER/PA with updated COBRA General Notices has been
explained by a representative of Infinisource. The ER/PA agrees that the process of mailing General
Notices should be completed immediately and agrees to the following:

Infinisource is authorized to send approximately _________COBRA General Notices on behalf of the
ER/PA. Data to perform the mailing will be supplied to Infinisource via Microsoft Excel spreadsheet.
Infinisource will supply the spreadsheet to the ER/PA upon receipt of the signed and dated General Notice
Memorandum of Agreement.

Infinisource will send the notices via first class mail.

Undelivered notices will be returned to the ER/PA to be re-sent at its discretion with instructions on how to
complete correctly.

All documentation regarding the mailing will be returned to the ER/PA for their records.

Infinisource will charge $3.00 per General Notice sent.

Infinisource will send an invoice with appropriate charges immediately following completion of the
mailing. Payment is due within thirty days of the date the invoice is sent.

Have you been certified for the Trade Assistance Act by the Department of Labor? Yes or No

Do you have an HMO health plan? Yes or No

Please list the legal name of your group health plan(s) __________________________________________
______________________________________________________________________________________
*If you do not include the legal name of your group health plan, Infinisource will list is as “Group Health
Plan(s) sponsored by {{Company Name}}.”

Please list the contact name, address, phone and fax for the group health plan(s) ______________________
______________________________________________________________________________________
*If you do not include the contact information, Infinisource will use the company contact information that
we currently have in our system.

Please list the e-mail address of where to send the spreadsheet ____________________________________
*If the e-mail address is not completed Infinisource will use the company contact information that we
currently have in our system.

__________________________________________________
Authorized Signature                           Date

Please fax this completed Memorandum of Agreement to 517-279-9420 Attention General Notice Blanket
Mailing Team.

				
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