Laserfiche WebLink
Infinisource COBRA Renewal Agreement <br />Section 1: Fees and Consideration Appendix- Fees due with agreement unless otherwise noted <br />Employer shall pay as compensation to Infinisource, for its performance as herein described for the services indicated, said sum itemized <br />and payable as follows: <br />Employer Legal Name: City of South Bend <br />Insured employees: 1,090 Number of reporting locations: 1 <br />COBRA fees are based upon one reporting location. Separate tracking for additional locations will require an additional annual fee per location. Employer <br />agrees to pay$10 per premium remittance check Issued. Direct deposit remittance is at no additional cost. <br />Special notes: *Service date is from 3/1/2017 - 2/28/2018. Discount applied. <br />All fees are non-refundable. <br />AppkonA <br />%ard of Pteblic Works <br />Please sign, date and return via <br />Employer <br />Signature <br />Infinisource Authorized Signature <br />Infinisource use only <br />Internal agent# <br />Date <br />Date <br />Agreement valid for 30 days from <br />Account# FC9945629 <br />Service effective date <br />15 E. Washington St. • PO Box 889 • Coldwater. MI 49036-0889. 800-300-3838 • Fax: 517-278-0764 - E-mail: solutions@infinisource.com <br />Copyright 0 2012 Infinisource, Inc. All rights reserved. 0042 <br />