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, HCSC COBRA ADMINISTRATIVE SERVICES <br /> HCSC COBRA Administrative Services Purchased: ❑ Yes � No <br /> If yes, please complete the COBRA sections below. If no, the COBRA sections below do not apply. <br /> � • • • • � • <br /> COBRA Administrative Billing Services Only: ❑ Yes ❑ No <br /> COBRA Administrative Full Services: ❑ Yes ❑ No <br /> Notification Services included: (Full Services): ❑ Yes ❑ No <br /> Conversion Rights included: (Full Services): ❑ Yes ❑ No <br /> Monthly Reports" included: ❑ Yes ❑ No <br /> *Paper reports provided by maiUelectronic reports via email If Yes, <br /> Email Address: <br /> Effective date(s) of services if different from ASO Effective Date of Coverage: <br /> • � • <br /> Billing Services Fee per Participant per month: $10.00 <br /> If Notification Services included(Full Services) <br /> Notification Fee (per Participant for each notice): $10.00 <br /> Monthly Administrative Fee: $75.00 <br /> The Employer will pay HCSC a sum of One Hundred Dollars ($100.00) per �100.00 <br /> hour for any system programming costs associated with non-standard <br /> administration services. <br /> • : � • - . <br /> Number of Active Members": <br /> Number of current COBRA participants/members*: <br /> Number of current COBRA retiree participants/members*: <br /> *Full Service Unit(FSU)set-up of participants/members in BlueStar required <br /> FSU Location: <br /> FSU Contact: Phone Number: <br /> Email Address: Fax Number: <br /> Is all COBRA participant census information attached? ❑ Yes ❑ No <br /> Is all COBRA participant coverage(s)and level elected information attached? ❑ Yes ❑ No <br /> Is all dependent census information attached? ❑ Yes ❑ No <br /> HCSC IL GEN ASO BPA Rev. 9.1.10(On-line Version) page 7 <br />