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HomeMy WebLinkAboutC99-007 Mountain State Administrationsent Ay: nano; ani ann Annn; nPn-PA-AA R : PI Pau; PAOR APSi 3&-1200142 L I FE OF CANAW �11 P10 DEC 23 198 09: 09 Sun of 7` r of UAMCW & 1 A ,amber of $ten 01W9,sl Group IVA AT SPOLICYHOLDER AND THIRD PARTY ADM NLSTRATOR W EAGLE COUNTY GOVERNMENTAGREEMENT RE1W$1SN AND MOUNTAIN STATES ADMINISTRATION (Policyholder) (Third Pay Adminlarrarnr) ("the Pollcyholder") delegates to MOUNTAIN STATES ADMINISTRATION MaThin! any Adrainistmtor") full authority to performs " following am on behalf of the policyholder with NOW to the stoup policy Me policy") issued by Sun Life of Canada CSun Life"). yes No (Cheek Appropriate Box for Each Item Ddmv) t. [3 [j prepsr:tian of a warn u of prmlam; 2. ( [l Payment of Pftiniums go sun Life; 3. [3 C] Raoaipt of copii,"t of prOndUm ovMuc nod0w, including Canaslladam; A. Q s. ( 0 -7. ❑ 9. C3 D 10. Cl E IRieiadon sad coordinatiors of &vwn&n=w ea the Plan Oaoutnont and rrt irmoaare of all alient,s Wor"Iiles'. initittlott of pee-canification. utiliZWOn review and Case ManMement on behalf of the policyholder; Pmpatacion of 50% clairn notifications artd complete subIldW003 to request mimbvDomtnt, when eldnumc rowhaca or I&NOW,a the specific dar#uatibloc Praparrdon of Agg. Insumnes monthly claims reports and the filing of AgSM80a tnwranco claims; Forwarding Svidolm of Lsswrabilicy or Sun We; Initiation and maipt or sit oar comwa&nce, including but not limited to mucwa anniveraary infummden. with raupect to the Sun Life policy or Polleyholder's plan Oncurnant; Any other Administtau've futtedons delegated to the TPA') The Third Parry Administramr shalt maintaln, at its principal administrative ofl'lee, adequate books and records of all transactions relating to the subject pulicy and AW1 retain such buakb and rcc cards for the periud rcgtdred by law, with Sun Life having We right tc access thereto upon teasenable prior ra lea. Sun Life is authorized by EAGLE 'COUNTY GOVER*ENj#V* Policyholder") to conduct business for On preceding purposes with the adininiatrator. The administrator is the agent of the policyholder, not the agent of Sun Life. The administrator shall hold all fronds fWaived by it In a fiduciary capacity and shall immediately remit such hutds to the person eRtldsd ghoreto. This notice is cflective from the daio bolow imdl the polieyholder nodfics Sun Life in wriunat of the termination of the above relationship. Termination of the polio atone not and the agency relationship. THE THE TPA BY: *nTLE. TFTLE! 1/4/99 -�� t1 DATE: * DATE: C (to be Signed by the Policyholder and TPA °o ..a Sun Life • (Group Office:) ACKNOWLEDGED BY SUN UFE: TME: DATE: