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GGFM-ER-8514 Maxwell Health Employer Information Form 02/24 <br />Billing and administration, continued <br />Billing Structure: <br /> Single bill with all employees and coverages <br /> Single bill with employees grouped by: <br /> Location Division/department Other: ______________________________________________ <br /> Multiple bills split by: <br /> Location Division/department *Benefit Other: ________________________________ <br />*If grouping or splitting the bill by benefit, please define here: ________________________________________________ <br />Please provide Billing Location details below (if more than two, e-mail the additional information). <br />Billing Location/Division/Department/Benefit - 1 <br />Name of location (if applicable) No. of employees at location <br />Name of benefits administrator at this location Title <br />E-mail address Phone number <br />Street address City State Zip code <br />Billing Location/Division/Department/Benefit - 2 <br />Name of location (if applicable) No. of employees at location <br />Name of benefits administrator at this location Title <br />E-mail address Phone number <br />Street address City State Zip code <br />If your billing, administration or claims will be administered by a Third Party Administrator (TPA), please fill out the <br />contact information below. (If unsure, consult your broker or one of our Implementation Consultants to help you. <br />What is the role of the TPA?: Premium Claim Premium and Claims <br />Name of TPA firm E-mail address <br />Name of contact person at TPA firm Title Phone number <br />Street address of firm City State Zip code <br />Docusign Envelope ID: BA987120-63B9-40BD-A4CA-C6E248AD9B65 <br />X <br />X