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' � 10. Transfer Payment Agreement Specifications(cont'd): <br /> (b) Payment Period <br /> ❑ Daily <br /> ❑ Semi-weekly <br /> �'Weekly <br /> ❑ Other: <br /> (c)Ciaim Settlement Period <br /> �'Monthly <br /> ❑ Quarterly <br /> ❑ <br /> (d)Term of Agreement: � one year ❑ years <br /> (e) Final Settlement to be made�_month(s)after termination of agreement. <br /> ADDITIONAL SERVICES: <br /> COBRA Administration by FDL: ❑ Yes ❑ No <br /> Individual Benefits Management Program (IBMP): ❑ Yes ❑ No <br /> (Freestanding Program not part of MSA Program) <br /> If yes: <br /> Adminstration Fee: $ per hour plus expenses computed on an individual case basis. <br /> Special Human Organ Transptants Coverage: ❑ Yes ❑ No <br /> (A separate Application must be completed) <br /> Administration of ReimbursemenUSubrogation Provision: ❑ Yes ❑ No <br /> If yes: ❑ Reimbursement Provision Only <br /> ❑ Subrogation/Reimbursement Provision <br /> FEE: ❑ Standard Fee <br /> 0 <br /> ADDITIONAL PROVISIONS: c r 1 ;�Q,� ,, ��'n,�- -�` � �Q� <br /> -� �� « ^ � <br /> '`-'' � �Yn9xtit, ', <br /> ti�`F�`-�'1���Q(� 1�--�s;--F �,M .l�- �c-�-�-�� ;LD,'y�.��rt�. �, <br /> � �+ � <br /> �. u, � '' C r � <br /> Sales Represe a�ive n ture of Authorized Re resentative of E yer <br /> �`fo `T� �� '... 1 "� ��- �' - 3� � - Citv Manager <br /> District U Phone Number Titfe <br /> �z��. n,� � (�,�,. , ,�-�`� �; c September 22 , 1992 <br /> Brokerege Representative Date <br /> 1�G�,���e�!-��� , �: 3 1 <br /> Brokerage Frm W��� <br /> GA-10-4 HCSC Rev.3/92 Page 3 <br />