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Do I Qualify?

Do I Qualify?

Employee #1

Dependants:
Name Relationship Date of Birth

Employee #2 (optional - click to expand)

Do I Qualify?
Administrative Service Agreement
BETWEEN:

OLYMPIA BENEFITS INC‚ of 2300 – 125 9th Avenue SE
Calgary‚ Alberta T2G 0P6 (hereinafter called "Olympia")
–and–
the Employer

WHEREAS:
  1. The Employer has established a Private Health Services Plan‚ a summary of which is included in this document‚ for its employees and their dependants (hereinafter called the Employee Health Care Plan): and
  2. Olympia is engaged in the business of providing financial‚ administrative and trustee services;
Olympia and the Employer hereby agree as follows:
Responsibilities of Olympia

Olympia shall provide the following services to the Employer:

  1. Olympia will provide consultation to the Employer with regard to requirements to establish the plan for its employees.
  2. Olympia will assist the Employer with implementing the plan.
  3. Olympia will administer and manage the plan on an ongoing basis.
  4. Administration of the plan will include but not be limited to the following:
    1. Establishing Accounts for eligible Employees, as authorized by the employer.
    2. Confirming that claims meet eligibility requirements.
    3. Monitoring claim pools to ensure account maximums are not exceeded.
    4. Establishing client reporting procedures.
    5. Processing elections on year end account balances.
    6. Processing and distributing claims from accounts.
    7. Arbitrating contestable claims between Employee and Employer.
  5. Olympia will follow the guidelines and procedure manuals set forth by respective Provincial Health Information Acts and the Federal Freedom of Information and Privacy Protection Act.
  6. Olympia will be entitled to all interest earned on temporary account funds.
  7. Olympia shall monitor Employer’s account funds and notify the Employer’s designated Benefit Coordinator(s) by email, fax or mail (whichever is most expedient and readily available) whenever the account falls below levels deemed to be acceptable by Olympia.
Responsibilities of the Employer
  1. The Employer will ensure that the plan remains funded as outlined in the Application for Benefits, in a manner necessary to meet its obligations to its employees and Olympia. In the event that the employer fails to fund the plan as required, Olympia is under no obligation to, and will not pay out claims submitted by the employees.
  2. The Employer shall provide Olympia with a current record of all eligible employees and dependents covered under the plan.
  3. The Employer shall notify Olympia immediately about changes affecting the eligibility of any employees and/or dependents in a manner that is satisfactory to Olympia.
  4. The Employer shall maintain a registry of all eligible employees signifying which employees are participating in the plan and which employees are opting out.
Other Terms
  1. The Employer authorizes Olympia to apply payments from the Employer’s account in settlement of eligible benefits payable to employees under the plan and settlement of administration fees due to Olympia, and to make adjustments to accounts to comply with the Application for Benefits.
  2. Olympia shall not be liable in the event that it has paid a benefit for which an employee was not eligible because the Employer failed to supply Olympia with timely or accurate information in a manner satisfactory to Olympia.
  3. This agreement can be terminated immediately by either party upon written notice to the offices of the other party. Termination of this agreement constitutes termination of the plan.
  4. In the event this agreement is terminated, Olympia shall have no obligations under the plan beyond paying claims incurred prior and including the date of termination. The Employer shall be required to fund its obligations under this agreement, including fees and applicable taxes due to the administrator, up to and including the date of termination.
  5. This agreement, together with the Employee Enrolment Forms and the Application for Benefits, constitutes the entire agreement.
    6. No agent or other persons has authority to waive any conditions or restrictions of this agreement; to make or modify this agreement; or to bind Olympia by making any promise or representation or by giving or receiving any information.
  6. The administration fee as defined on the active Plan Application will remain consistent throughout the duration of the administrative relationship between the Employer and Olympia.
  7. In addition, Federal and Provincial sales taxes will be levied on fees when applicable.
  8. In the event that the actual number of eligible employees at start up should differ from the number indicated on this schedule, an adjustment will be made to the employers account.
  9. Fifty dollars ($50.00) will be charged for all NSF cheques.

I‚ an authorized representative of the employer‚ hereby confirm that the above named employee is eligible under the terms of the employee health care plan and that the employee is entitled to be reimbursed for eligible medical expenses as herein described. The undersigned agrees to notify Olympia Benefits of any changes to the plan initiated by the employer.


I agree.