R96-148 AUTHORIZING APPLICATIONS

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•Current EmploymenURetirement Status ' • •Covera e Effective Date 9 •Coverage Termination Date •Group Plan Number •Benefits Provided (e.g., Hospital only, medical benefits only) •Coverage (e.g., individual, family, family but not spouse) Information on the Employer •Name and address of employer that pays the bill for coverage The Employer agrees that the Claim Administrator's ability to make accurate primary/secondary MSP determinations depends on the breadth and accuracy of the Claim Administrator's files con- cerning Covered Persons. The Employer agrees to use best efforts in responding promptly and accurately to the Claim Administrator's requests for information and to require and facilitate its employees' cooperation in responding promptly and accurately to such requests. � Further,to assure the continuing accuracy of the Claim Administrator's files,the Employer agrees I that it is the Employer's responsibility to notify the Claim Administrator promptly of any change ' in the size of the Employer's work force or status of its employees that might effect the order of payment under the MSP statute,such as information regarding working-aged persons who retire and changes in the size of the Employer's work force that place it in, or take it out of, the scope of the MSP statute. If the Claim Administrator does not receive such information from the Em- ployer, the Claim Administrator will assume that all relevant factors remain unchanged and will process claims accordingly. The group acknowledges and agrees that the Claim Administrator • will be using the information provided by the Employer and Covered Persons to update the Claim Administrator's files, and will also forward this information to HCFA so that HCFA can revise its file to reflect relevant changes in primary/secondary status. The Claim Administrator may, in its sole discretion, discontinue its participation in the Data Match system as described above. Nothing in this Agreement shall be construed as obligating the Claim Administrator to continue its participation in the Data Match system. C. Disclosure Statement The Employer acknowledges that the Claim Administrator has furnished it with a copy of a pam- phlet entitled "Information Regarding the Medicare Secondary Payer Statute" (also referred to as the "Disclosure Statement"), prepared by the BlueCross and BlueShield Association and re- viewed by HCFA, which administers Medicare. XVII. ERISA A. As defined in Section 3 of ERISA, the term "employee welfare benefit plan" includes any plan, fund or program which is established or maintained by an employer or by an employee organiza- tion, or by both, to the extent that such plan, fund or program was established or is maintained for the purpose of providing for its participants or their beneficiaries, through the purchase of in- surance or otherwise, medical/surgical or hospital care or benefits,or benefits in the event of sick- ness, accident or disability. The Employer hereby acknowledges (i) that an employee welfare benefit plan must be established and maintained through a separate plan document which may include the terms hereof or incorporate the terms hereof by reference, and (ii) an employee wel- fare benefit plan document may provide for the allocation and delegation of responsibilities there- under. However, notwithstanding anything contained in the Plan or any other employee welfare • benefit plan document of the Employer, the Employer agrees that no allocation or delegation of any fiduciary or non-fiduciary responsibilities under the Plan or any other employee welfare bene- fit plan of the Employer is effective with respect to or accepted by the Claim Administrator. - 11 -