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CARRIER - RATE INFORMATION FOR COBRA m0aZIMNAM" Carrier/Rate Information for COBRA (Save this form as a template-reuse it as many times as necessary to list all of your carriers.) Client Name EIN # City of Clearwater 59-6000289 Complete Carrier/Provider Name(i.e.,XYZ of North Carolina) Type of Coverage 0 Medical El Dental El Vision CIGNA El Hearing El Rx El HRA E3 Other(as follows) Plan Description 0 HMO Z PPO El POS [I EPO El Indemnity El Other(as follows) If Medical,does the medical plan include OAPIN HIGH prescription coverage? N Yes El No Begin and End Effective Dates of the Plan Year�(mm/ddlyyyy-mm/ddlym) Policy/Group Number 01/01/2009 - 12131/2009 3331468 Monthly Rates MGM= If Age/Gender $875.47 $875.47 $8 5.47 $1440.45 $1440A5 attach rate grid If provider plan is bundled or packaged,this coverage line must be taken with: [I Medical EJ Dental El Vision El Hearing El Rx El HRA El Other(as follows) Type of Coverage Complete Carrier/Provider Name(i.e.,XYZ of North Carolina)CIGNA 12] Medical El Dental El Vision El Hearing El Rx El HRA Plan Description If Medical,does the medical plan include Ej HMO [E] PPO F-1 POS F-1 EPO Ej Indemnity El Other(as follows) OAP prescription coverage? N Yes E:1 No Begin and End Effective Dates of the Plan Year:(mm/dd/yyyy-mm/dd/My) Policy/Group Number 01/01/2009 - 12/31/2009 3331468 Monthly Rates (without 2%) If Age/Gender 77 $936.44 4 $1540.75 $1540.75 attach rate grid I If provider plan is bundled or packaged,this coverage line must be taken with� El Medical El Dental El Vision El Hearing El Complete Carrier/Provider Name(i.e.,XYZ of North Carolina) Type of Coverage 123 Medical El Dental El Vision El Other(as follows) - Plan Desc tion If Medical,does the medical plan include [0 HMO OPO Ej POS Ej EPO E:1 Indemnity Ej Other(as follows) prescription coverage? 0 Yes No OAPIN BASIC Begin and End Effective Dates of the Plan Year:(mm/dd/yyyy-mm/dd/yyyy) Policy/Group Number 01/01/2009 - 12131/2009 331468 Monthly Rates (without 2%) attach rate grid If provider plan is bundled or packaged,this coverage line must be taken with! El Medical F1 Dental 171 Vision [:1 Hearing Ll Rx El HRA E] Other(as follows)_ ~Attach m rate grid showing all Age/Gender rates and tiers (CALIFORNIA: clearly identify which plans have active COBRA enrollees). Provide monthly rate for each applicable coverage choice without the 2% COBRA administration fee. From Date hone Please provide carrier/rate information for all 10/31/08 72-7-5-6Z -07�' COBRA-eligible plans Ceridian is to administer. Ceridian Benefits Services Inc. 3201 34 th Street South,St.Petersburg, Florida 33711-3828 * (800)790-9057 * Fax(800)272-9654 Carrier/Rate Information for COBRA, CarrierlRate Information Page 2 of 2 Geridian Benefits Services Inc. s 3201 34""Street South,St. Petersburg, Florida 33711-0828 0 (800)790-9057 a Fax(800)272-9554 t t a tt{ss3t� � r tit r� r tt t� 141 ash rr te�i� r4hi, . �S t a C 44' }5�4 4 � t 1r��t r t�yS !it~ itm m 7 rsiRt� — y is t�Fait f€ j 4� 4t 4J1�l� 1 J il h •s�Ji'rk 3I k 5}"rj r�ltJ� t 4l(y } � Ceridian COBRA& HIPAA Services Proposal �r , r G METHODOLOGY COBRA and HIPAA Administration Investment 4 3 t t iX Implementation fee Included 4 10 t r Takeover fee for current continuants Included ru Qualifying Everts Included '- (up to 20% of covered population) Qualifying Events F� (greater than 20% of covered population) $20.€10 each Monthly service fee $777.42/mo. / a (1851 active covered employees t� Q$0.42 per employee x 12 months) $932 .04/yr. Initial COBRA notification services for new covered lives Included Additional rate plans setup TBD s ($150 flat fee for more than six plans) �1 Additional locations setup { C$25 per location reporting to Ceridian TBD -- Annual Renewal Fee Included t STANDARD COBRA,SERVICES: S k� z�so r Takeover audit of current Collection processing t}'] continuants Correspondence a Qualifying Event notification by Web access for customer and first-class mail with proof-of- artici ants ';- mailing p p Toll-free telephone support to Initial COBRA notification continuants and customer Sa services for new covered lives by premium allocation reports a LISPS first-class mail with proof p of-mailing Premium distribution to Election processing employer t t� fk s Accounting/auditing reports to Bad check collections - }1 customer Updates required by law Monthly invoices Archiving of all records a rt)y P a�i Cerldlan COBRA&HIPAA Services Proposal € k�raw�t 4d 0 0 a K F } v Initial COBRA notification to all current covered lives based on Ceridian receiving data Via electronic format -$2.75 per notice Via paper format -$3.25 per notice HIPAA Certificates for active loss of coverage ($4.00 monthly minimum or$0.08 PEPM) E Eligibility reporting to carriers Paper ($150.011 one time set-up fee,$80.00 per month per carrier) tt n I'M Electronic('$300.00 one time set-up fee,$20.00 per report per carrier) ;r Premium disbursement to carriers 1� $10.00 per carrier per month $15.00 per carrier per month,if employer subsidizes premiums `T Open Enrollment for COBRA continuants Pull($1,000 set-up,plus$15.00 per continuant,plus postage) Passive ($1,000 set-up,plus$8.00 per continuant,plus postage) ' Partial ($8.00 per continuant,plus postage) c f� ,py OPTIONAL COBRA SERVICES: f f Initial COBRA notification to all current covered lives by USPS first-class r , mail with proof-of-mailing HIPAA Certificates of Creditable Coverage for active loss of coverage by t "MM LISPS first-class mail with proof-of-mailing MAW Eligibility reporting to carriers 'a Premium distribution to carriers ?pen enrollment services 19 MM Standard services }l Ceridian standard file specifications Ceridian retains 2%-administrative fee paid by continuant(When Ceridian bills a participant a subsidized rate,we do not charge the customer/participant the standard 2 administration fee. Ceridian charges the customer a set administration fee per invoice of$6.00). f'za Six rate plans setup w Three inbound reporting locations setup o One reporting location to customer All benefits terminate on the same date u � Standard data specifications and media A 4% annual adjustment to monthly administration fee may apply - upon renewal. Ceridian COBRA &HIPAA Services Proposal �� _... RIDIAN Contract Services �m=~ �°��°°,~�~~, °~=� A |ndiCafeI required information 1 1131 �7 �=0281/01/09 AClient Name Federal Taxib# (9 digits) Desired Effective Date City of Clearwater -6000289 Electronic Bill E-Mail Address: AlComplete last page for Automatic Payment Service (APS) AMailing Address city State County Zip 100 South Myrtle Ave Clearwater fl 33756 -i—Street Address(if different) city State County Zip A 1'Contact Name,Title: Allan DelPrete A 2 Ind Contact Name,Title: Anna Fierstelin Phone: 727-562-487(p Fax: Phone: 727-562-4875 Fax: A#of Locations/States: ATotal Employees: ACovered Employees: SIC Code: 2156 1851 COBRA Continuation Services—Cigna Standard Services Optional Services Service Fee, (Per Employee Per Month) $0.42 El COBRA Notification to all current employees—Electronic$2,75 Implementation Fee Included El COBRA Notification to all current employees— Paper$3.25 Renewal Fee Included El HIPAA Certificates($4.00 monthly minimum or$0.08 PEPM) Takeover fee for current continuants S27.00 Additional Fees New Hire Notifications Included Additional rate plans setup for >6 rate plans $150.00 Flat Fee Qualifying Events Included Additional locations setup for >3 locations $25.00 each This is to acknowledge that the Client has reviewed and understands the terms,conditions,and information as stated in this Contract for Services.The Client acknowledges responsibility to pay fee(s)for services performed|fCJGNA(Agent/emker)*does not pay all or any pert of the fee(s)for services performed. The Client agrees to be bound by all terms and conditions stated on this Contract for Services and attachments.Any changes to this document are not binding unless initiated by both parties. INITIAL the two statements below,SIGN and INCLUDE both General Terins&Conditions and CarrierlRate Jnfprinatian for Cobra with this Contract. Client has reviewed and agrees to the Terms and Conditions set forth on page ii of this document. Client has received and will be bound to the service obligations set forth in the Service Manual included with this document. ACCEPTED eYCLIENT: AGREED roaYcnm/o/AN BENEFITS SERVICES ~�~ 10s10 AuFt7orl-zed ClientPepre5entatnfe Signature, Title Date Xelth VaSSI310ffl, VICe Pre9dent and C01*011er Date A g nt/Broker/Referrer Name *Agent e If Broker Referrer Company Name Invoice Broker? Lynne Swift or Dina D'Angelo Cigna,South Florida E Yes* El No 7� Address city County State Zip 1571 Sawgrass Corp Pkwy Sunrise Broward FL 33323 Telephone Fax E-mail Address Ceridian Agent# -T-el 1954-514-6872 lynne.swift@cigna.com *Authorized Broker Representative (Signature) Date Agent/Broker by signature of its Authorized Broker Representative above represents and warrants that this contract complies with all applicable state insurance laws and regulations.Agent/ Broker also agrees to pay the fee(s)for services performed "M"9 ff M- "IM711IF! ----- I SalesRepresentative: John Jenkins (727)865-3186 1 @2OO8[ehgian Corporation—iv.mmv|ii www.ceridian.com Page iofU General Terns and Conditions 1. Parties:'Ibis Agreement is between the client identified on the Contract S. Disposition of Data:Except as expressly provided in an applicable Service for Services("Client")and Ceridian Corporation and/or its subsidiaries Manual(s),Ceridian will not be responsible for storing copies of Client's ("Ceridian"),each of which may be referred to in the singular as"Party"or records when Ceridian no longer requires such information in order to in the plural as"Parties". provide Services to Client.Client will reimburse Ceridian for the costs of producing any information in Ceridian's possession or control relating to 2. Term and Termination:This Agreement will become effective when Client's business or employees that Ceridian is obligated to produce in signed by Client and accepted by Ceridian(the"Effective Date").It will, response to a Client request or court order.Upon termination of this except as provided in Article 6,continue for an initial term(the"Initial Agreement,Ceridian will dispose of Client's records and data unless Term")of one year(winless otherwise stated in an Exhibit or Amendment otherwise previously directed in writing by Client. to this Agreement)beginning with the Effective Date and shall continue thereafter until terminated by either Party upon 90 days prior written 9. Intellectual Property:All materials,including but not limited to forms notice. (including data collection forms provided by Ceridian),brochures„tip sheets, posters,and online content("Materials")furnished by Ceridian to Client are 3. Fees and Payments:Client will pay the fees set forth in the attached licensed(not sold).Client is granted a personal,non-transferable and Service Quotation(s)and/or Exhibit A(s),including any applicable taxes. nonexclusive license to use Materials solely for Client's oven internal Ceridian shall not increase fees during the Initial Term of the Agreement. business use.Client does not have the right to copy,distribute,reproduce, After the Initial Term,Ceridian reserves the right to increase prices alter,display,or use these Materials or any Ceridian trademarks for any other annually with 30 days'prior written notice to Client.All reasonable and purpose.Client agrees that(a)it will keep Materials confidential and will use customary travel expenses incurred by Ceridian in support of the Services commercially reasonable efforts to prevent and protect the content of will be billed at actual cost to the Client.Ceridian may charge a late Materials from unauthorized use and(b)its license to use Materials ends on payment fee in the amount of I'l,°/>per month for delinquent payments the termination date of this Agreement.Upon termination,Client agrees to made by Client.Client agrees to pay late payment fees and any costs of destroy Materials or,if requested by Ceridian,return them to Ceridian. collection. 10. Limitation of Remedies:Ceridian will indemnify and hold Client harmless 4. Services:Except as provided herein,Ceridian shall provide the services from and against any and all claims alleging that the Services and Materials ("Services")identified on the Contract for Services and described in the furnished by Ceridian violate any third party's patent,trade secret,copyright, attached Service Manual(s).Services provided to Client that are not within or other intellectual property right.Ceridian will also indemnify and hold the scope of this Agreement will be mutually agreed upon between the Client harmless from and against any and all claims for bodily injury Parties,subject to the terns and conditions of this Agreement and billed at allegedly caused by Ceridian.EXCEPT AS EXPRESSLY SET'FORTH IN Ceridian's then current price.Any exception fees,late fees,or THIS AGREEMENT,THE MAXIMUM TOTAL LIABILITY OF miscellaneous fees will be subject to the terms of this Agreement and CERIDIAN TO CLIENT SHALL BE LIMITED TO DIRECT MONEY billed at Ceridian's then current price. DAMAGES IN AN AMOUNT NOT TO EXCEED THE GREATER OF(A) 5. Changes:In the event of a change in federal or state laws or regulations THE TOTAL AMOUNT PAID BY CLIENT FOR THE DEFECTIVE affecting the Services provided under the terms of this Agreement, SERVICE CAUSING THE DAMAGE DURING THE 12 MONTHS Ceridian may make changes to the Agreement,including the Exhibits,with IMMEDIATELY PRECEDING THE LOSS,OR(B)510,000.THIS 30 days'prior written notice to Client.if,upon notification of the change, REMEDY IS CLIENT'S SOLE AND EXCLUSIVE REMEDY. Client elects not to continue Services,Client may terminate this CERIDIAN SHALL NOT BE RESPONSIBLE,FOR ANY SPECIAL, Agreement upon 30 days'prior written notice without penalty or INCIDENTAL,CONSEQUENTIAL,EXEMPLARY,OR PUNITIVE cancellation fees. DAMAGES EVEN IF CERIDIAN HAS KNOWLEDGE OF THE 6. Termination for Cause:If either Party does not materially meet its POSSIBILITY OF SUCH POTENTIAL LOSS OR DAMAGE.CERIDIAN obligations as set forth in this Agreement within 30 days after receiving WILL NOT BE RESPONSIBLE FOR FAILURE TO PROVIDE SERVICES written notice of the breach,then the other Party shall have the immediate IF DUE TO ANY CAUSE OR CONDITION BEYOND THE right to provide written notice of terrrrination of this Agreement. REASONABLE CONTROL OF CERIDIAN. Additional termination rights may be set forth in the attached Service 11. Warranty Disclaimer:THE EXPRESS WARRANTIES SPECIFIED IN Manual(:).Client's obligation to pay all charges that have accrued will THIS AGREEMENT ARE IN LIEU OF ALL OTHER WARRANTIES, survive any termination of this Agreement. EXPRESS OR IMPLIED,INCLUDING WITHOUT LIMITATION,ANY 7. Confidentiality and Privacy:Neither Party shall disclose Confidential WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A Information of the other Party.The receiving Party shall use the same PARTICULAR PURPOSE.CERIDIAN DISCLAIMS AND EXCLUDES degree of care as it uses to protect its own confidential information of lake ALL OTHER WARRANTIES. nature,but no less than a reasonable degree of care,to maintain in 12. Notices:All notices,requests and communications to the Parties shall be in confidence the confidential information of the disclosing Party.The writing(including fax or similar writing)and shall be given to the Parties at foregoing obligations shall not apply to any information that(a)is at the their respective address identified on the Contract for Services or to such time of disclosure,or thereafter becomes,part of the public domain other address or fax number as either Party may hereafter specify by notice through a source other than the receiving Party,.(b)is subsequently learned to the other Party.Each such notice,request or communication shall be from a third party that does not impose an obligation of confidentiality on effective upon receipt,provided that if the day of receipt is not a business the receiving Party,(c)was known to the receiving Party at the time of day,then the notice shall be deerned to have been received on the next disclosure,(d)was generated independently by the receiving Party,or(e) succeeding business day. is required to be disclosed by law,subpoena or other process. Ceridian may transfer Client's Confidential Information to a governmental agency 13. General Provisions:(a)This Agreement and the Parties rights and or other-third party to the extent necessary for Ceridian to perform its obligations shall be governed and construed pursuant to the laws of the state obligations under this Agreement or if Client has given Ceridian written of Minnesota and Client consents to be subject to the jurisdiction of the state authorization to do so.For purposes of this paragraph,Confidential or federal courts located in Minnesota;(b)Client may not assign this Information shall mean any information identified by either Party as Agreement except with Ceridian's prior written approval;(c)No action "Confidential"and/or"Proprietary",or which,under the circumstances, under this Agreement may be brought by Client more than two years after ought to be treated as confidential or proprietary,including non-public the cause of action has accrued. information related to the disclosing Party's business,employees,service methods,software,documentation,financial information,prices and 14. Entire Agreement:This Agreement constitutes the entire agreement product plans.Ceridian reserves the right to independently use its between the Parties with respect to the subject matter hereof,and supersedes experience and know-how,including processes,ideas,concepts and all prior or contemporaneous agreements and understandings regarding the techniques developed in the course of performing Services under this subject matter hereof,whether written or verbal.Any amendment to this Agreement.Ceridian shall appropriately safeguard all Protected Health Agreement must be in writing and signed by authorized representatives of Care Information("PHI")made available to Ceridian while rendering both Parties. Services.Ceridian will comply with all laws applicable to its Services. Q 2008 Ceridian Corporation—iv.mmviii www,ceridian.com Page ii of ii Ceridian Benefits Services,Inc. Service Manual Ceridian COBRA and IIIPAA Services A. DUTIES OF CERIDIAN: Commencing on the effective date of Client's agreement with Ceridian to which this Service Manual is attached and incorporated by reference("Agreement"),Ceridian is authorized and instructed by Client to implernent and follow the COBRA and HIPAA statutes and the regulations thereunder to provide the following services with respect to the Plan(s)for consideration,as stated in the Client Quotation attached. 1. COBRA; Ceridian shall: (a) Advise covered employees and qualified beneficiaries under COBRA in writing of their rights to elect and continue to receive COBRA continuation coverage under the Plarr(s),after Client has notified Ceridian of the occurrence of one of the events set forth in Section B(1)(a)(i)through(vii), below,with respect to such individual; (b) Collect premiums(plus administrative charges)from or on behalf of continuants,who elect to continue coverage under the Plan(s),and forward the amount of the paid premiums(excluding the 2%administrative charge paid by continuants and any earnings on the paid premiums retained by Ceridian) to Client(or as otherwise mutually agreed between the parties)on a monthly basis unless Client chooses optional service(for a fee)to have Ceridian remit premiums directly to the insurance carrier(HMO premiums are forwarded weekly and non-HMO premiums are forwarded monthly); (e) Advise Client in writing of the status of each continuant electing continued coverage under the Plan(s)within 14 business days after the end of each month. These status reports will include continuants who are current on th,eirpayments,and those cancelled for failing to remit payments pursuant to the requirements of COBRA,as implemented in accordance with this Agreement, (d) Provide Client,upon request,with forms to be used to notify Ceridian of a"qualifying event,"as that team is defined under COBRA.; (c) Provide notification containing the information required to be included in the COBRA initial notification(ERISA Section 606(A)(1))to all employees of Client and dependents who are participants under the Plans)and whose names and addresses are furnished by Client; (f) With respect to services provided by Ceridian under this Agreement,Ceridian shall maintain proof of services performed by Ceridian for a period of seven years. Ceridian shall consider COBRA premiums to be timely paid if,within 30 days of the due date,such premiums are actually delivered to Ceridian,postmarked by the U.S.Postal.Service or sent by express delivery service(with evidence thereof),unless Client advises Ceridian in writing that a longer period applies under the Plan(s). Actual delivery,postmark or evidence of express delivery will also be used to determine timeliness of COBRA elections based on applicable statutory periods. Ceridian shall not be responsible for reviewing the Plan(s)in any respect or for comparing the Plan(s)with the group health plan sponsored by another employer or Medicare. 2. HIPAA (a) Issuance ofCcrtificates of Creditable Coverage("Certificates") (1) Ceridian shall issue a Certificate with respect to each Plan(s)participant or dependent entitled to receive a Certificate under HIPAA, provided that Ceridian is notified in writing(or as otherwise agreed to by the parties)of the individual's loss of coverage(or entitlement to COBRA coverage)or of the individual's request for a Certificate in accordance with Section B(2)of this Agreement. (2) All Certificates issued by Ceridian shall indicate the date of issuance ofthe Certificate and all information required by HIPAA and the Regtilations. (3) All Certificates shall be sent by Ceridian by U.S.Postal Service first class mail(with proof of mailing)to the affected participant or dependent or to the party requesting a Certificate or otherwise designated by a participant or dependent to receive a Certificate and shall be sent to the address provided to Ceridian by Client pursuant to Section B(2)of this Agreement. (4) Ceridian shall send a duplicate Certificate with respect to each individual covered under the Plan(s),at no additional cost,where an initial Certificate already has been issued,provided that the written request for such duplicate Certificate is made within 24 months of the individual's loss of coverage under the Plan(s). (S) Notwithstanding any other provision herein to the contrary,Certificates shall be issued by Ceridian on behalf of Client only to the extent required by applicable law and only in connection with losses of group health coverage(or entitlement to COBRA coverage)occurring on or after October 1,1996(and occurring between July 1,1996 and September 30,1996 i f requested by a participant or dependent),unless otherwise agi`ced to in writing between the parties,and shall only include information regardimg periods ofcoverage retroactive to July 1, 1996. Any services requested by Client that are not within the scope of the foregoing shall be governed by a separately negotiated agreement between the parties. (b) Certificates that Ceridian is authorized to Issue pursuant to Section A(2)(a),above,shall be issued by Ceridian within a reasonable period of time following the date upon which Ceridian receives from Client all of the information required for the issuance of the Certificate as set forth in Section A (2)(a)(2). In the event that all of the information required to be included in a Certificate is not provided by Client,Ceridian shall request from Client the missing information and,if such information is not provided within three(3)business days from the date the request is made,Ceridian shall notify Client that a Certificate will not be issued. Ceridian shall not issue a Certificate unless and until Ceridian receives(i)all,of the required information;or(if)written instructions to issue the Certificate without all of the required information and a written indemnification from Client in the form provided by or otherwise satisfactory to Ceridian. (02008 Ceridian Benefits Services,Inc. Ail rights reserved Page I Ceridian COBRA and HIPAA Services 2WY?-CH-03 Ceridian Benefits Services,Inc. Service Manual Ceridian COBRA and HIPAA Services (c) Ceridian shall provide Client with a written summary confirming the individuals to whom Certificates were issued. Ceridian shall store data provided by Client with respect to periods ofeoverage ofparticipants and dependents tinder the Plan(s)retroactive to October 1, 1996(or July 1,1996,if requested in writing)and shall retrieve such data in connection with the issuance of Certificates. With respect to services provided by Ceridian under this Agreement,Ceridian shall maintain proof"of services performed by Ceridian for a period of seven Years. 3. General Ceridian shall provide a toll-free telephone number for access to a Customer Service Representative,who will be available during normal Ceridian business hours (8.00 a.m.to 8:00 p.m.Eastern Time,Monday through Friday,except Ceridian holidays)that may be used by Plan(s)participants and dependents(or their authorized representatives)in connection with the services provided by Ceridian under this Agreement. With respect to Ceridian's HIPAA and COBRA responsibilities above in addressing correspondence to qualified beneficiaries and other individuals, Ceridian is instructed,where practicable,to use zip+4,(through United States Postal Service approved Accumail or other computer program)for those addresses that are furnished to Ceridian without such information,and to use its best efforts to correct or complete addresses that it recognizes to be incorrect or incomplete. B. DITTIES OF CLIENT I. COBRA, Client shall advise Ceridian of any of the following events,but in the case of(a)(i)through(via)below only those events that would result in the loss of coverage by a participant under Client's Plan(s): (a) (i)Death of a covered employeelretiree;(ii)Termination of employment of a covered employee(for reasons other than gross misconduct)or reduction in the employee's hours;(iii)Divorce/legal separation from the covered employee;(iv)Covered employeeiretiree becoming entitled to benefits under Title XVIII of the Social Security Act(Medicare);(v)Dependent children who cease to be eligible as"dependents"under the terms of the Plan(s);(vi) Client filing for bankruptcy(provided that if Client files for bankruptcy under title 11,U.S.C.,Client shall advise.Ceridian of any loss or substantial elimination of coverage under the Plan(s)(with respect to employees,dependents,retirees,surviving spouses and their dependents)occurring within one year before or after the commencement of the bankruptcy proceeding);and(vii)Any other event resulting in a covered employee and/or dependent becoming qualified to continue coverage under the provisions of COBRA; (b) A qualified beneficiary being determined,under Title It or XVI of the Social Security Act,to have been disabled at any time during the first 60 days of continuation coverage or that the qualified beneficiary is no longer disabled. Such notice(s)shall be provided to Ceridian as soon as practicable,but in no event later than 5 business days after the date Client becomes aware of such event;and (c) The termination of any of the Plan(s),such notice(s)to be provided at least 30 days prior to,or,if less,as soon as practicable in advance of,the termination ofthe Plan(s). The notices described in Section B(1)(a)(i)through(vii),above,are to be sent in writing to Ceridian on forms provided by Ceridian or in such other form as is agreed to in writing between the parties within 14 days of the date of the occurrence of the event described therein(irrespective of the date of loss of coverage under the Plan(s)). Client shall be solely responsible for determining whether or not an employee has had a qualifying event,has been terminated for gross misconduct or is or has been incompetent. Client shall be solely responsible for selecting a determination period,and establishing and advising Ceridian of the applicable premium rates to be charged for COBRA continuation coverage, Client shall notify Ceridian in writing:(i)at least 30 days in advance of the applicable billing date of any changes in premium rates affecting participants electing continued coverage under the Plan(s),and(ii)at least 30 days in advance of the applicable billing date of any changes in premiums applicable to participants during an open enrollment period. 2. IIIPAA (a) Within 14 days following the occurrence of an event that entitles a participant or dependent covered or formerly covered under the Plan(s)to receive a Certificate under HIPAA(as determined by Client),Client shall advise Ceridian of the information required to be included in the Certificate,as set forth in Section A(2)(a)(2). This information must be provided to Ceridian by Client in writing on forms provided by Ceridian,or in such other form as is agreed to in writing between the parties.Client shall be solely responsible for determining whether or not a participant or dependent(or an individual acting on a participant's or dependent's behalf)is entitled to or should be sent a Certificate pursuant to HIPAA. Client acknowledges and agrees that Ceridian shall use the information furnished by Client to prepare the Certificate to be issued;all such information will be true and accurate as of the date such information is sent to Ceridian. If any information furnished to Ceridian by Client changes following the date sent by Client,Ceridian shall not be responsible for issuing a Certificate reflecting such new information,unless requested by Client in writing. Any such additional Certificates shall be treated as separate Certificates, and the appropriate fee shall be charged to Client. Where Client is aware that information furnished to Ceridian is not accurate,Client shall promptly notify Ceridian by a form of media designated by Ceridian)that clearly identifies the affected individual and provides the correct information as of the date of transmission. (b) Client shall be solely responsible for providing Ceridian with the appropriate last known address for the individual or entity to whom a Certificate is being issued in accordance with HIPAA and the regulations. ,02008 Ceridian Benefits Services,inc. All rights reserved Page 2 Ceridian COBRA and HIPAA Services A40-0H-03 Ceridian Benefits Services,Inc. Service Manual Ceridian COBRA.and HIPAA Services 3. General Client represents that the Plan(s)will be maintained during the term of this Agreement in accordance with HIPAA,COBRA,ERISA,the internal Revenue Code of 1986,as amended(the"Code")and other applicable law. Client,the Plan(s)'administrator and/or the Plan(s)(and their agents or assigns),and not Ceridian,shall be solely responsible for the review and payment of claims for benefits under the Plan(s)and all appeals under ERISA,including,without limitation,with respect to claims,benefits and eligibility determinations Linder the Plan(s). C. CLAIMS Notwithstanding anything in this Agreement to the contrary,Ceridian shall not be responsible to receive or review claims for benefits under the Plan(s)or be liable for the payment of any claims for benefits under or in connection with the Plan(s)or any group health plan,including,without limitation,where sought as damages in an action against Client,Ceridian or otherwise. Client agrees to hold Ceridian harmless(including reasonable attorneys fees and costs)and expressly releases all claims against Ceridian in connection with any claim or cause of action,which results from the failure or alleged failure of Client(its officers and employees,and any entity related to or performing services on behalf of Client,including,without limitation,any insurance company providing services to or on behalf of the Plan(s))to comply with HIPAA,COBRA,ERISA,other applicable law or the provisions of this Agreement,and any occurrences prior to the effective date of this Agreement. D. AUDIT RIGHTS Client may during the term of this Agreement and for a period of two(2)years thereafter inspect any HIPAA creditable coverage or COBRA compliance transactions, procedures,records and tiles relating to Client's employees(and their dependents),at Ceridian's office and at a time reasonably acceptable to Ceridian,upon providing 10 business days advance written notice to Ceridian. E. RELATIONSHIP OF PARTIES Client and Ceridian acknowledge and agree that Ceridian is retained under this Agreement as a representative of Client,the Plan(s)and/or the plan administrator of the Plan(s)to assist them with their obligations to comply with the provisions of HIPAA relating to the certification of creditable coverage and the continuation coverage provisions of COBRA,and that Ceridian is not a fiduciary under ERISA and lacks any discretion hereunder. The parties hereto further acknowledge that Ceridian is an independeint contractor and not a joint venturer with or partner,agent or employee of Client. Nothing contained in this Agreement shall be deemed to permit either party to conduct business in the name of or on account of the other party,to incur or assume any expense,debt,obligation,liability,tax or responsibility on behalf of or in the name of the other party,or to act on behalf of or bind the other party in any manner whatsoever,except for the taking of actions by Ceridian on behalf of Client in the course of fulfilling its duties under this Agreement. The parties agree that Client shall for all purposes be considered under HIPAA as the entity that issued the Certificates that are distributed by Ceridian pursuant to this Agreement. F. RELIANCE BY CERIDIAN Client has authorized and instructed Ceridian in Section A to implement its standard administrative procedures to provide services in accordance with this Agreement. Ceridian shall be fully protected in relying upon representations made by or on behalf of Client. Ceridian shall also be fully protected and indemnified and held harmless by Client in relying on the accuracy of any information provided by Client,either orally,in writing or otherwise,in effecting its actions and obligations under this Agreement. Client and Ceridian agree that if Client provides Ceridian with specific instructions to provide services in a manner other than in accordance with Ceridian's standard procedures,Ceridian may(but need not)comply with Client's written instructions,provided that,if Ceridian complies with such instructions,Client and not Ceridian shall be solely responsible for Ceridian's actions so taken,and Client agrees to hold Ceridian harmless(including reasonable attorneys fees and costs) and expressly releases all claims against Ceridian in connection with any claim or cause of action,which results from or in connection with Ceridian's following Client's written instructions. Ceridian may require that requested changes be provided in writing in a form acceptable to Ceridian,within its sole discretion. Client represents that the signatory to this Agreement is authorized to enter into such Agreement on behalf of Client. Client(and its agents or assigns),and not Ceridian,shall be responsible for the administration of the Plan(s)and all appeals under COBRA,ERISA,1-IIPAA,and other applicable law,including,without limitation,with respect to claims,benefits and eligibility determinations under the Plan(s),COBRA,ERISA,and/or 111PAA. G. ELECTRONIC DATA FILE TRANSFERS The provisions of this Section shall apply to any electronic data file transfers between Client and Ceridian. (a) Each party shall properly use those security procedures,if any,which are reasonably sufficient to ensure that all transmissions of documents are authorized and to protect its business records and data from improper access. (b) Ceridian shall not be required to confirm or verify the accuracy,authenticity or completeness of any information provided by Client. Ceridian's only obligation shall be to compile such information accurately and to utilize such information in performing its responsibilities. (c) Client is responsible for verifying the receipt of data by Ceridian from monthly reports sent to Client. (d) Documents shall not be deemed to have been properly received,and no document shall give rise to any obligation,until accessible to the receiving party. Any document properly transmitted pursuant to this Agreement shall be considered to be a"writing"or"in writing,"and any such document when containing,or to which there is affixed,a signature shall be deemed for all purposes(i)to have been"sib ed,"and(ii)to constitute an "original"when printed from electronic fields or records established and maintained in the normal course of business. (e) Ceridian shall not be liable for and Client shall indemnify Ceridian with respect to any damages(including reasonable attorney fees and court costs)that may result from its utilization of inaccurate or incorraplete information received from Client. 6-2008 Ceridian Benefits Services,inc. All rights reserved Page 3 Ceridian COBRA and HIPAA Services MC-CI-1-03 Ceridian Benefits Services,Inc. Service Manual Ceridian COBRA and HIPAA Services (f) Email can be used to supplement or replace telephone calls to Ceridian. During email use,Ceridian is not responsible for any message or data that is lost or altered in transit,misinterpreted upon receipt,or electronically directed to the wrong employee at Ceridian- Email is not an acceptable method of transmitting COBRA or HIPAA data. (g) The fallowing methods are acceptable methods of transmitting COBRA or HIPAA messages or data: EFT,CD,3 '/"diskettes(in tape specifications as ag7-eed by both parties);Ceridian Web enabled applications;and manual paper forms(provided by Ceridian.) H. RESPONSIBILITY OF PARTIES Except as expressly provided to the contrary herein,neither Ceridian nor Client shall be responsible for any damages to the other under the terms of the Agreement or arising out of their respective responsibilities hereunder,unless such damages directly result from:(i)the failure of one of the parties to fulfill any of its duties under this Agreement,or(ii)the dishonest,fraudulent,or criminal acts of a party,its employees,directors,or officers,acting alone or in collusion with others. In reference to COBRA services under this Agreement,Ceridian and Client,each agree to protect,defend and indemnify the other from and against any Charges(as defined below)arising out of or resulting from the breach by the other party of any provision of this Agreement,such amounts payable upon a Determination of Liability(as defined below)in accordance with the terms set forth below. For purposes of this Section: (a) The parties acknowledge and agree that this Agreement is a legally enforceable written agreement within the meaning of Section 498013(e)(2)(A) with respect to and to the extent of the services that Ceridian is obligated to provide hereunder. Ceridian shall pay for excise taxes imposed upon it under Section 498013(c)(1)(B)of the Code based on the Agreement,subject to the aggregate limits under Section 498QB(c)(4)(C)of the Code,provided that Ceridian retains all rights to challenge or seek a waiver from the Internal Revenue Service with respect to all or any portion of such excise taxes,and provided further that Client,and not Ceridian,shall have responsibility with respect to such excise taxes in cases where such tax assessments arises out of Client's act or failure to act or Ceridian following the instructions provided by Client. (b) "Charges"means(i)excise taxes imposed under Code Section 498013(e)(1),subject to the provisions of the aggregate'limitations set forth in Code Section 4980B(c)(4)(C)and the right of the assessed party to challenge the Internal Revenue Service with respect to all or part of the imposition of such excise taxes;and/or(ii)penalties(in an amount tip to$110 per day)that are imposed by a court under Section 502(c)(1)of ERISA and that are paid,but shall exclude the payment of the claims for medical benefits under the terms of any group health plan,and,which in the case of(i)or(ii)are incurred as a direct result of the other party breaching the Agreement; (c) "Determination of Liability"means:(i)the agreement by the indemnifying party("Indemnitor")that it has committed a breach ofthe Agreement that directly resulted in the incurrence of a Charge by the party seeking indemnification("Indemnitee")in response to a notice from the Indemnitee to the Indemnitor via Certified mail asserting liability under this provision,and requesting payment,or(ii)a determination by a court of competent jurisdiction in a final nonappealable decision issued in a case in which the Indemnitor is a party,which decision finds that the Indemnitor has committed a breach of the Agreement that directly resulted in the Indemnitee incurring a Charge;and (d) Notwithstanding anything in this Section to the contrary,neither party shall be entitled to indemnification tinder this Section in circumstances where the Charge(s)sought hereunder result from:(i)the Indemnitor following the written instruction of the Indemnitee;(ii)reasonable reliance by the Indemnitor on information furnished by the Indemnitee;(iii)the actions or inactions of the Indemnitor in circumstances where the Indemnitor requested,but did not receive,information or guidance from the Indemnitee,which information or guidance the Indemnitee is obligated to provide under the Agreement or which is within the sole control of the Indemnitee under the applicable group health plan;(iv)the improper,illegal,fraudulent or negligent actions of the Indemnitee;or(v)a matter in which the Indemnitee fails to notify the Indemnitor within fifteen days after the Indemnitee first becomes aware of the assessment or suit against it for which indemnification will be or is sought hereunder. L Monies Received Are General Assets Notwithstanding any provision in this Agreement to the contrary,Client and Ceridian intend and agree that the monies received by Ceridian and forwarded to Client as provided in this Agreement:(i)are and shall remain the general assets of Client;(ii)are not the general assets of Ceridian;and(iii)are not"plan assets"within the meaning of ERISA. 02008 Ceridian Benefits Services,lire. All rights reserved Page 4 Ceridian COBRA and HIPrfA Services AIO-CIf-03 I AM PA JC-- Carrier/Rate Information for COBRA (Save this form asetemplate-reusenas many times as necessary to list all of your carriem.) Client Name EIN City of Clearwater 59-6000289 ° NOTE: Clients must complete and submit both pages of this form to ensure proper plan set-up. Select a Benefit Package Option below M Unbundled Plans: any offered coverage type may be taken alone F1 Bundled Plans: the entire benefit package must be offered as a whole(all coverage types),a COBRA-Participant has the option toelect"core coverage"types only. "Core Coverage"ia any coverage type other than dental and vision. El Sometimes Bundled Plans: certain coverage types are required habe taken together,while others may bo taken alone, Please specify what coverage type(o)must be offered together below, F� Packaged Plans: all coverage types must be offered together Select Age and/or Gender Rate Rules Please note the following: Cor}dian will utilize the Employee rate mm the default for the age and/or gender rate table. Ceridian does not adjudicate per child rates or rates based on a spouse's age band. Attach a rate grid showing all Age/Gender rates and tiers (CALIFORNIA: clearly identify which plans have active COBRA emn»||eem). A carrier invoice will not provide the required information. Provide monthly rate for each applicable coverage choice without the 2% COBRA administration fem. Please review the questions below and contact your carrier representative if clarification of your rate structure is necessary to answer both questions correctly. \ &m-- 1. Should the participant be billed ot the rate for their: (check one) /'m El Age Attained ' or - El Age they are nearest within 8months 2. Should the rate change occur at: (check ono) |/�' �~ 1p� [l The start of the billing cycle following the participant's birthday or' M The start uf the billing cycle containing the participant's birthday or' [] The beginning of the plan year or E] The end uf the plan year -or- [1 The end mf the calendar year Provide Healthcare Account Directives Do you currently offer o Healthcare Flexible Spending Account? R Yes El No FSA Administrator Name&Address (if applicable) A-/'Z 0n you want Ceridian to administer COBRA for this Healthcare Flexible Spending Account? Yes No Must Medical plan be taken mIong with this Healthcare Flexible Spending Account? El Yes No |f you have a Health Reimbursement Arrangement, must a Medical plan be taken along w�bx �� y�� F-1 N� this HRAbene�iplan? ^4(�� 0o you want (]eridianto administer COBRA for this Health Reimbursement ArmsngamenL?��pd 0 Yes 0o conieoRutemformamm Page ,mo Crndian Benefits Services Inc. ° 3201 o4m Street South,St. Petersburg, Florida nar11'ae2n * (800)790-9057 * Fax(aOg)zr2'96n*