Common Contracts
1 similar null contracts
Plan Services AgreementMaryland • May 22nd, 2018
Physical Address: City: State: ZIP: Mailing Address: City: State: ZIP: Billing Address: City: State: ZIP: Type of Business: SIC: Tax ID: Corporation Partnership C-Corp S-Corp Sole Proprietorship Other Name/Address of subsidiaries/affiliates to be included: If subsidiaries/affiliates are included, do you want separate bills sent to each of these subsidiaries/affiliates? YES NO List prior insurance carrier or Third Party Administrator (TPA): Current Medical Group Health Plan:If this plan is replacing current group coverage, please provide the most recent copy of your Fully-Insured Self-FundedN/A Section 2: Invoicing and Payment (check one) Deposit must include the first month's fixed costs and the first month's maximum claims cost. Requested Effective Date: Deposit with Application: $ . Checking this box enables electronic billing and therefore waives the billing fee. In place of receiving a paper invoice, you will need to log on to your
