Healthcare Liens in Personal Injury Cases: Mastering the Fundamentals of Subrogation

10/1/2019

A Trusted Personal Injury Firm In Hof & Reid LLC, comprises a team of attorneys with more than 100 years of combined legal The Lehigh Valley For Over 75 Years experience. Based in Bethlehem, Pennsylvania, we have been serving people and businesses throughout the Lehigh Valley since 1942. Our attorneys offer a diverse range of legal services with an emphasis on all types of injury claims, including brain trauma, burns, amputations, spinal injuries and other serious harms. Our personal injury attorneys provide aggressive and loyal representation. Whether the case involves a car accident, a defective product or a dangerous property condition, we are prepared to help.

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1 10/1/2019

Treasure Trove of Attached Materials

• PowerPoint Slides • Fundamental Subrogation Checklist • Medicare Subrogation Flowcharts • Sample Notification Letters • Compromise Request Letters • Letter to ERISA Plan Administrator • ERISA Form 5500

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What is Subrogation?

Definition: The substitution of one party in place of another with reference to a lawful claim, demand, or right, so that he who is substituted succeeds to the rights of the other.

Subrogor DERIVATIVE of injured CONTINGENT upon (person injured) party’s claim, thus subject injured party having cause to third party’s defenses of action against injured party

Subrogee Third Party (insurance company) (tortfeasor)

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AN EQUITABLE DOCTRINE

Subrogation = equitable principle, deeply rooted and founded upon natural justice. Origins in equity; whether guided by state law, federal law, or contract – still guided by equitable principles In the past, not pursued vigorously………………….so WHY NOW?

• Billion dollar industry • Increased focus on bottom line • Emphasis on reducing claims, cutting costs, etc. • Helps insurance companies recoup losses • Decreases net recovery to injured

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Have Your Cake and Eat it Too?

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Types of Subrogation

Legal Contractual Statutory • Origins in • Per agreement • Most recent equity • Insurance policies • Giveth and • No need for • Healthcare Plans Taketh Away contract

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Subrogation in Personal Injury Cases

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Subrogation for Auto Accident Cases

75 Pa.C.S.A.§1720 of the Motor Vehicle Financial Responsibility Law (MVFRL) (enacted 1984) Section 1720:  No right of subrogation from claimant’s recovery, including employers for workers comp  1993  Act 44 repeals 1720 as it relates to workers comp. benefits. Section 1722:  Prohibits injured to recover amounts not subject to subrogation by third party  Statutorily eliminates the common law collateral source rule*  *The collateral source rule permits injured party to recover all damages caused by the tortfeasor, irrespective of whether the injured party received monies or benefits from another source (i.e., a collateral source, typically the injured’s insurer)

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Subrogation for Auto Accident Cases

EXCEPTIONS TO MFVRL’S ANTI-SUBROGATION CLAUSE: Workers Compensation (Act 44) Federal Preemption  Medicare  Medicaid (DHS)  FEHBA  ERISA HMOs

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Flowchart for Subrogation in Auto Cases

Did injuries arise from maintenance or use of a No.motor vehicle? Yes.

Unrestricted right to Did Plaintiff receive benefits for injuries subrogation. from:  Federal program (Medicare)  State program (DPW)  Self-Funded ERISA Plan  HMO  Workers Compensation carrier Practice Pointer: Lien is  Federal Employees Health Benefit Act boardable even if (FEHBA) insurance company not actively pursing No. Yes. reimbursement. (Probably) no right of Right to subrogation subrogation

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Subrogation for Workers Compensation

• PA Workers’ Compensation Act provides exclusive remedy against employer; limited to medical expenses and wage loss

• Employee retains right to sue third party tortfeasor for negligence • Ex) UPS delivery person bit by dog.

• 77 P.S. Workers Compensation§671 – Governs subrogation

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Subrogation for Workers Compensation 77 P.S. Workers Compensation§671

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Subrogation for Workers Compensation

77 P.S. Workers Compensation§671

• Vests “employer” with a statutory right of subrogation against third party Practice Pointers: • Employer = workers comp insurer and • Size of lien often prevents actual employer (usually insurer) normal reduction from being sufficient • Prevents injured worker from obtaining • Get in touch with workers double recovery comp. adjuster early. • Subpoena presence for • Formulaic reduction for attorney settlement conference. fees/costs • Consider 3-way split

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Subrogation for Workers Compensation

Workers Comp / UM and UIM Motorists Coverage • If an employee recovers UM or UIM benefits from his or her own automobile policy, the employer has no right of subrogation against that recovery because the benefits were not from a third- party but from the employee’s own policy for which the employee paid premiums • HOWEVER, if employee recovers benefits from UM/UIM policy of employer, co-worker, or customer, then employer retains right of subrogation • NOTE: Plaintiff can still plead, prove and recover the workers’ comp benefits in UM case even though WC insurer would have no right of reimbursement against that personal UM recovery. Ricks Nationwide Ins. Co., 879 A.2d 796 (Pa. Super. Ct. 2005).

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Subrogation for Premises Liability Unrestricted right of subrogation. • Includes any private health plan (ERISA and non-ERISA)  Plan must have subrogation clause (look at language)  Many provisions expressly exclude reductions regardless of attorney fees, costs, or amount to client.  NOTICE: Not required. Contractual obligation. May have laches argument.  Negotiation tactics – discussed with ERISA liens. Trust us to fight for you.

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Subrogation for Premises Liability

Silver Lining………………..? Collateral Source Rule. All medical bills, including health insurance payments, may be recovered. In reality, does not often matter because subrogation lien will exist for same amount.

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Subrogation for Medical Malpractice

 Medical Care Availability and Reduction of Error (MCARE) Act, (Act 13) (March 2002)  Similar framework to Section 1720 of MVFRL:  Generally no subrogation except for federal preemption (Medicare, DHS, ERISA, etc.)  Silent on Workers’ Comp  Abrogates collateral source rule with some exceptions  NOTE: Unlike MVFRL, option to introduce all medical bills, but only as persuasive evidence of non-economic damages (not for economic loss recovery)

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9 10/1/2019

ETHICAL CONSIDERATIONS

Pennsylvania Rules of Professional Conduct and Subrogation: Rule 1.1 - Competence  “Dabbling” in Personal Injury Law  Knowledge of Subrogation laws Rule 1.5 - Diligence  Notice to Subrogors Rule 1.5 – Fees  Evaluating and compromising liens Rule 1.15 - Safekeeping Property  Escrow funds for lien payoff Rule 4.1 – Truthfulness in Statements to Others  Negotiating lien compromises Trust us to fight for you.

Subrogation Troublemakers 1. ERISA 2. Medicare 3. DHS

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ERISA Plans - Background • ERISA = Employee Retirement Income Security Act, 35 P.S. §5701.1303(b)(2) • Comprehensive scheme for federal supervision and protection of employee benefit plans • Secondary source of coverage (i.e., after first party benefits exhaust) • U.S. Airways v. McCutchen, 569 U.S. 88 (2013). • SCOTUS ended the circuit split on whether equitable defenses apply in ERISA subrogation claims • Held that equitable defenses will not apply if the Plan language disavows them • If Plan is silent, then default rule = equitable common fund doctrine (i.e., reduce for attorney fees) • McCutchen legacy = Plan language will rule whether and to what extent ERISA Plan must be reimbursed

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ERISA Plans – Must be Self-Funded • Is the ERISA Plan self-funded • Most important inquiry in effort to negotiate the lien. • If no  • does not preempt MVFRL • no right to subrogation • If yes  • at mercy of Plan’s language for subrogation • How do you know if the Plan is self-funded?.....

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11 10/1/2019

ERISA Plans – Form 5500 • Form 5500 • Federal filing that must be filed annually by ERISA employer • Go to www.freeerisa.com and search by employer (it’s free) • Look at page 1, elements 9a (plan funding arrangement) and 9(b) (plan benefit arrangement). Each lists the following options: • Insurance • Section 412(e)(3) • Trust • General assets of the sponsor • If boxes (3) and (4) are marked on both  self-funded • If (1) and/or (2) are marked  look at attached schedules…

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ERISA Plans – Form 5500 Attached Schedules • Form 5500 – Attached Schedules • Look for Schedule A (if none, skip to Schedule C) • Look for named insurance company under Part 1(a) • Next, look for Part III(8) • 8(a) should be marked “Health” (tells you this is health plan) • If any other box in section 8 is marked other than (i)  plan is not self-funded  no subrogation • Schedule C • Look for references to “claims processing”, “contract administrator”, and “plan administrator” • An insurer providing insurance would not be listed on a Schedule C and therefore is indicative of a fully self-funded Plan

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ERISA Plans – Documents to Request • Statutory request pursuant to Section 1024(b)(4), Title 29, US Code. • Send request to Plan Administrator (not Third Party Claims Administrator) • Documents to Request: • IRS Form 5500 • The actual (“master”) Plan • Summary Plan Description • Copies of modifications/amendments to Plan/Summary from d/o/l to present • Subrogation / Reimbursement language from the Plan • Annual Report for the Plan for year that MVA occurred • Itemized statement of amounts/benefits paid o/b/o client with medical bills and corresponding CPT codes • Administrative service contract b/t employer and plan admin in effect on d/o/l • 30 days to respond; otherwise, $100/day penalty may be imposed Trust us to fight for you. • See Form Letter attached hereto

ERISA Plans – Negotiation Tactics and Ethical Client Management STRATEGY TACTICS • Look at language • If no clear abrogation, made-whole doctrine applies • Must identify particular fund out of which reimbursement must occur separately from beneficiary’s general assets (Sereboff v. Mid Atlantic Medical Serv., Inc.) • Must expressly disavow attorney fees • Be relentless with document requests and review. • Concede McCutchen, offer “pragmatic” approach with focus on resolution; consider 3-way split • Threaten that client will drop claim completely if no reduction • Do not have client sign release until reduction is negotiated ETHICAL CLIENT MANAGEMENT • Mention early and often (PA Rule Prof. Conduct 1.4 – Communication) • Get agreement in writing (PA Rule Prof. Conduct 1.2 – Scope of Representation) • Explain consequences of not settling lien (PA Rule Prof. Conduct 1.4 and 1.5 – Communication / Fees)

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13 10/1/2019

MEDICARE – Background • Federal program (1965) to provide aged and disabled with health insurance • Preempts state law (e.g., Section 1720 of MVFRL) • Administered by Centers for Medicare and Medicaid Services (CMS) via the Benefits Coordination & Recovery Center (BCRC) Medicare Secondary Provision Act (42 U.S.C. §1395y(b)) – enacted in 1980 • Medicare has subrogation right for all past medical expenses incurred prior to settlement / judgment / award • Medicare Set-Asides • Medicare’s obligation to pay for future medical treatment after case resolves. Remains gray area, but Regulations expected soon.

• Notice --- “Medicare beneficiaries, through their attorney or otherwise, must notify Medicare when a claim is made against an alleged tortfeasor . . . This obligation is fulfilled by contacting the BCRC.” - www.cms.gov

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MEDICARE CHECKLIST

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MEDICARE and Conditional Payments • Double-check the treatment – review with client to make sure it’s related to the accident • Dispute unrelated charges • Do not rely on amounts for conditional payment letters • Ex) You settle case for $50,000 based on $14,000 conditional payment. Medicare issues final conditional payment amount at $40,000. Client is responsible for final amount.

Practice Pointers • Client should not sign third-party release until final conditional payment letter has been received. • Finalize settlement soon after receiving final conditional payment

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Department of Human Services (DHS) • Federal program (1965) to provide aged and disabled with health insurance • Until 2014, known as Department of Welfare (DPW) • Administers PA’s Medicaid program: provides medical and cash assistance • Counsel must be aware of: • DHS’s subrogation rights • Duty to notify DHS / protect its interests • Potential liability for distributing third-party recovery before satisfying DHS’s interests • Duty to verify accuracy of lien amount

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15 10/1/2019

Department of Human Services

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Department of Human Services (DHS) • Waiver (unlikely) • Undue hardship to beneficiary (or heirs for wrongful death) • Compromise • DHS entitled to entire amount, except: • Reasonable litigation expenses deducted • Cannot exceed 50% of the beneficiary’s net recovery • Must share in attorney fees • Only applies to medical expenses (past – not future); does not extend to non-economic damages • Arkansas DHS v. Ahlborn, 547 U.S. 268 (2006).

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17 10/1/2019 Christopher Meyer Reid | Hof & Reid LLC | Bethlehem, Pennsylvania

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Christopher M. Reid

Partner

Location: Bethlehem, Pennsylvania

Phone: 610-628-2355

Fax: 610-258-0390

Email: Email me https://www.valleyinjury.com/About-Us/Christopher-M-Reid.shtml 1/5 10/1/2019 Christopher Meyer Reid | Hof & Reid LLC | Bethlehem, Pennsylvania

Christopher Reid is an experienced trial attorney. He has successfully tried over one hundred jury trials and arbitrations. Mr. Reid has represented hundreds of clients whose lives have been adversely aected as a result of automobile accidents, medical malpractice, and defective products. Mr. Reid has counseled those clients through the litigation process with the compassion and respect they deserve, often recovering six and seven gure awards and settlements. Mr. Reid's focus in representing his clients is making sure that their voice is heard and their interests are protected to the fullest extent that the law allows.

Mr. Reid was born in 1974 in New York City. He grew up near Cleveland, Ohio, and spent time living in California before returning to Cleveland, where he graduated from high school. He received his Bachelor of Arts degree, cum laude, from the University of Toledo in 1996. Prior to attending law school, Mr. Reid worked on Capitol Hill as a legislative intern for United States Senator Jay Rockefeller (D-WVA) and as a legislative intern for the American Bar Association. Mr. Reid went on to Vermont Law School where he earned his Juris Doctor degree in 1999. More importantly, while at Vermont Law School, Mr. Reid met his wife Tara, and the two were married and in 1999 moved to the Lehigh Valley, where they live with their two beautiful children. Mr. Reid began his professional career as an associate attorney with the Easton rm of Seidel Cohen & Hof LLC in 1999. In 2003, Mr. Reid was made a member of the rm, and in 2007, the law rm of Hof & Reid LLC opened its Bethlehem oce.

Mr. Reid is a member of the Pennsylvania Bar Association, Northampton County Bar Association and Lehigh County Bar Association. He is also a sustaining member of the Pennsylvania Association for Justice. He is a past President of the Northampton County Bar Association and served on its Board of Governors for seven years. He is a past President of the Board of Directors for the Community Action Committee of the Lehigh Valley and a current Board member. Mr. Reid worked closely with local agencies, attorneys, county ocials and the Northampton County Court to develop and implement Northampton County's Mortgage Foreclosure Diversion Program to help county residents aected by the mortgage foreclosure crisis. Mr. Reid has given lectures on various personal injury topics including the following: Litigating the Nursing Home Malpractice Case, Evaluating the Medical Malpractice Case, Nuts & Bolts of Handling a Motor Vehicle Accident Case, UM & UIM Coverage Issues, and Medicare, ERISA, and other liens and subrogation issues.

In addition to spending time with his family, Mr. Reid enjoys playing tennis, golf, and snowboarding. He is still a diehard Cleveland sports fanatic, providing him with the only source of misery in his life.

https://www.valleyinjury.com/About-Us/Christopher-M-Reid.shtml 2/5 10/1/2019 Christopher Meyer Reid | Hof & Reid LLC | Bethlehem, Pennsylvania Areas of Practice

75% Automobile/Car Accidents (including UM and UIM cases)

5% Trucking/Tractor Trailer Accidents 10% Medical Malpractice

5% Nursing Home Malpractice 5% Products Liability

Litigation Percentage

100% of Practice Devoted to Litigation

Bar Admissions

Pennsylvania, 1999 U.S. District Court Eastern District of Pennsylvania, 2002

U.S. District Court Middle District of Pennsylvania, 2007

Education

Vermont Law School, South Royalton, Vermont J.D. - 1999

The University of Toledo, Toledo, Ohio B.A. cum laude - 1996 Major: Political Science

Honors and Awards

Pennsylvania Super Lawyers, Rising Star, 2010 - Present Pennsylvania Bar Association, Pro Bono Award, 2009 - Present

Professional Associations and Memberships

Pennsylvania Association for Justice (fka PATLA), Member, 2000 - Present American Bar Association, Member, 1999 - Present

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Pennsylvania Bar Association, Member, 1999 - Present Northampton County Bar Association, Member, 1999 - Present

Northampton County Bar Association Board of Governors, 2007 - 2015

Past Employment Positions

Laub, Seidel, Cohen & Hof, LLC, Associate Attorney, 1999 - 2003 United States Senator Jay Rockefeller (D-WVA), Legislative Intern, 1995

Pro Bono Activities

Northampton County Mortgage Foreclosure Diversion Program

Car and Motorcycle Accidents

Premises Liability

Products Liability

Medical and Nursing Home Malpractice

Tractor-Trailer Accidents

Wrongful Death

Estate Planning

Real Estate Transactions & Development

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Isaac A. Hof

Partner

Location: Bethlehem, Pennsylvania

Phone: 610-628-2355

Fax: 610-258-0390

Email: Email me https://www.valleyinjury.com/About-Us/Isaac-A-Hof.shtml 1/6 10/1/2019 Isaac A. Hof | Hof & Reid LLC | Bethlehem, Pennsylvania

Isaac Hof is proud to be an active trial attorney who practices in the Lehigh Valley and throughout Pennsylvania. He understands the importance of helping his clients navigate the legal challenges so often brought on by sudden tragedy. Equally important, Isaac knows what it takes to obtain the results his clients need to help them move forward with their lives.

Isaac has successfully represented injured victims in a variety of personal injury matters, including motor vehicle accidents (car, tractor-trailer, bus, motorcycle, pedestrian, and bicycle), premises liability (slip / trip and fall accidents), nursing home neglect, medical malpractice, FELA claims (railroad accidents), and products liability. He has litigated numerous claims at the municipal, arbitration and trial court levels throughout Pennsylvania. Isaac also serves as an Arbitrator for the Court of Common Pleas Northampton County Compulsory Arbitration program.

Isaac graduated summa cum laude from Temple University Beasley School of Law in 2012, where he received recognition for graduating with one of the ve highest GPAs in his class. Prior to joining the rm, Isaac served as a judicial law clerk for the Honorable Legrome D. Davis in the U.S. District Court for the Eastern District of Pennsylvania and subsequently practiced civil litigation at Stradley Ronon Stevens & Young, LLP in Philadelphia.

When not practicing law, Isaac enjoys spending time with his family, playing golf, and rooting for the Philadelphia Eagles. Isaac also is an avid runner. In 2018, he completed the AACR Philadelphia Marathon – a 26.2 mile race throughout the city of Philadelphia.

Areas of Practice

75% Personal Injury

10% Trucking/Tractor Trailer Accidents 10% Medical Malpractice

5% Products Liability

Litigation Percentage

100% of Practice Devoted to Litigation

Bar Admissions https://www.valleyinjury.com/About-Us/Isaac-A-Hof.shtml 2/6 10/1/2019 Isaac A. Hof | Hof & Reid LLC | Bethlehem, Pennsylvania

Pennsylvania, 2012 New Jersey, 2012

U.S. District Court District of New Jersey, 2014 U.S. Court of Appeals 3rd Circuit, 2014

U.S. District Court Eastern District of Pennsylvania, 2014

Education

Temple University Beasley School of Law, Philadelphia, Pennsylvania J.D. summa cum laude Honors: Order of the Coif Law Review: Temple Law Review, Lead Research Editor, 2010 - 2012

University of Maryland B.A. - 2008 Honors: With High Honors Major: Government and Politics

Published Works

WAKE-UP CALL: ELIMINATING THE MAJOR ROADBLOCK THAT CELL PHONE DRIVING CREATES FOR EMPLOYER LIABILITY, Temple Law Review, 84 Temp. L. Rev. 701, Spring, 2012

Employees Using Cell Phones While Driving Poses Major Liability Risk for Employers, Network Magazine, Autumn, 2016 Is My Auto Insurance Any Good?, Network Magazine, Spring , 2018

Self-Driving Vehicles: The Good, The Bad, and the Inevitable, Network Magazine, Summer, 2017

Classes/Seminars

Panel Member, Autonomous Vehicles - Driverless, But Not Lawless: An Exploration of How Self-Driving Cars Will Aect the Law and Litigation, Northampton County Bar Association , December 9, 2016 - Present Panel Member, Nuremburg: Justice or Retribution, November 2017

Panel Member, Northampton County Public Access Policy: What You Need to Know to Avoid Sanctions, November 2017 https://www.valleyinjury.com/About-Us/Isaac-A-Hof.shtml 3/6 10/1/2019 Isaac A. Hof | Hof & Reid LLC | Bethlehem, Pennsylvania

Panel Member, The Art of Persuasion: It’s Not What You Say But How You Say It, September 2017

Panel Member, Ethical Consider of Restoring Civility to Civil Litigation, August 2017

Honors and Awards

Selected to serve as a member of Bar Leadership Institute for Pennsylvania Bar Association , 2016 - Present

Jerry Zaslow Memorial Award, awarded to the law school graduate with outstanding academic achievement and activity within the law school community, 2012 - Present

Faculty Award for Academic Achievement, awarded to 5 students in the day division among the 5 highest GPA in graduating class, 2012 - Present The Barenkopf Scholarship, awarded to the law school student in the day division with the highest GPA going into the nal year of law school, 2012 - Present

Recognized by Temple Law professors for excellence in legal writing, oral advocacy, and overall academic achievement, 2012 - Present

Professional Associations and Memberships

Pennsylvania Bar Association, Member, 2012 - Present

Bar Leadership Institute of Pennsylvania Bar Association, Member, 2016 - 2017 Northampton County Bar Association

Lehigh County Bar Association

The Judge Donald E. Wieand Barristers Inn Pennsylvania Association for Justice, Board of Governors, 2018 - Present

Pennsylvania Association for Justice, Member, 2016 - Present

ProJeCt, Board Member, 2018 - Present

Past Employment Positions

Stradley Ronon Stevens & Young, LLP, Litigation Associate, 2013 - 2015

Honorable Legrome D. Davis, U.S. District Court for the Eastern District of Pennsylvania, Judicial Law Clerk, 2012 - 2013

https://www.valleyinjury.com/About-Us/Isaac-A-Hof.shtml 4/6 10/1/2019 Isaac A. Hof | Hof & Reid LLC | Bethlehem, Pennsylvania Pro Bono Activities

Wills for Heroes, 2016 - Present Holiday Hope Chest, Committee Co-Chair, 2018

Holiday Hope Chest, Contributor and Volunteer, 2017-Present

Car and Motorcycle Accidents

Premises Liability

Products Liability

Medical and Nursing Home Malpractice

Tractor-Trailer Accidents

Wrongful Death

Estate Planning

Real Estate Transactions & Development

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Fundamental Subrogation Checklist1

Following the incident, did the injured person receive health care treatment and if so, who provided and/or paid for the same, i.e., federal or state program, e.g., Medicare [including a Medicare Advantage Plan], Medicaid, veteran’s benefits, private insurer, possibly a Medicare Supplement Plan, etc.? If accident related medical and/or prescription bills were paid by Medicare and the injured person will likely require substantial medical treatment in the future, will a Medicare set-aside need to be established?

If medical bills were incurred as a result of the incident, were they paid for by an ERISA qualified employee benefits plan?

Following the incident, has the injured person received public assistance benefits, i.e., Medical or Cash Assistance from the Department of Human Services, formerly the Department of Public Welfare?

Following the incident, has the injured person received workers’ compensation or similar type benefits at the federal or state level, and if at the state level, were they received under another state’s workers’ compensation system?

What are the names and ages of the injured person’s children? Is a child support order in place? Is the injured person in arrears on his or her child support payments?

If the claimant is in child support arrears, a lien is created by operation of law against the net proceeds of any personal injury or workers’ compensation award exceeding $5,000 and said arrears are to be addressed prior to any distribution. See 23 Pa.C.S.A. § 4308.1. Note: per Campbell v. Walker, a domestic relations office can issue a non-distribution order precluding the distribution of any funds, not just funds in excess of $5,000 in net proceeds.

Following the incident, did the injured person receive or is he or she eligible for short or long-term disability? If so, are the benefits being paid pursuant to an ERISA qualified employee benefit plan? What must claimant discover and establish to determine an ERISA lien?

Is the injured person using sick, vacation, flex, or personal time while they convalesced?

1 Shollenberger and Mabius, Pennsylvania Personal Injury Subrogation Handbook (2017 ed.)

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How will attorney’s fees and costs be addressed-e.g., pro-rata sharing, etc.?

Will there be a prioritized manner of payment from the tort recovery, e.g., ERISA plan first, followed by counsel fees, then what is left over to the beneficiary?

What is the extent of the right of reimbursement, e.g., does it apply just to medical bills recovered or could it apply to any category of third-party recovery?

Is there a right of reimbursement against any UM or UIM recovery vs. a third-party recovery?

Can any equitable defenses, such as made whole doctrine, laches, etc. be used to defend against a subrogation/reimbursement claim?

Does the collateral source entity have a right of subrogation, right of reimbursement, or both?

Is there a duty to notify the collateral source entity of the third-party lawsuit, and/or of the third-party recovery?

Do any statutes or regulations apply to the client’s reimbursement obligation?

Is there a conflict of laws situation?

Does the state’s anti-subrogation law apply, and if so, will it be preempted by federal law?

Is there a specific federal or state subrogation/reimbursement statute that applies?

Is there a statute of limitations issue regarding subrogation/reimbursement rights?

Will there be issues regarding pleading the “lien”; will there need to be a special jury verdict form categorizing compensation; will the trial judge address the lien by molding the verdict, etc.

Were any letters of protection issued to a medical provider?

What are the potential consequences to the client and/or attorney for not promptly notifying and/or reimbursing the collateral source entity?

Is the collateral source entity willing to compromise its “lien”?

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Are there ethical considerations to consider?

Will a client’s comparative fault in getting injured have any impact on the extent of the reimbursement owed?

If the client’s reimbursement obligation is governed by contract, e.g., a self-funded ERISA Plan, is the language in the document ambiguous relative to reimbursement rights?

Will the court need to conduct a hearing on the merits with all interested parties as to the extent of reimbursement rights?

Has the client been fully advised of his or her potential reimbursement obligations and the potential ramifications of not complying with federal or state law, or contractual provisions relative to reimbursement obligations, e.g., assessment of interest, attorney fees, discontinuance of future benefits until reimbursement obligation satisfied, etc.?

Medicare’s Contractor is notified that a liability insurance Once a recovery case is established and posted on The initial compilation of (including self insurance), or the portal, the Beneficiary or his/her representative claims is posted to the worker’s compensation claim may access the recovery case through the portal and Medicare Secondary has been filed. notify CMS that a settlement is expected to occur Payer Recovery Portal within 120 days. The Final CP process can only be (MSPRP) within 65 days. initiated once per case.

The Beneficiary or his/her representative disputes claims and CMS responds within 11 days of receipt. Note: Disputes must be resolved prior to 3 days before settlement.

120 days or less before settlement: OR 30 days or less after settlement: The Beneficiary or his/her representative The Beneficiary or his/her representative notifies CMS, via MSPRP, that a downloads the Final Conditional settlement is expected. Payment amount, from the MSPRP.

The Beneficiary or his/her representative does not dispute claims.

The Beneficiary or his/her representative may submit a dispute on each conditional payment only once, but he or she is permitted to dispute relatedness on any conditional payment that has not already been disputed.

30 days or less after settlement: Medicare applies a pro rata reduction to CMS issues Final The Beneficiary or his/her representative the Final Conditional Payment amount Demand Letter. submits their settlement information, in accordance with 42 C.F.R.411.37. via the MSPRP.

Final Condition Payment (CP) Flow Chart 12.14.2015 May 20, 2019

Sr. Resolution Manager Gallagher Bassett P. O. Box 2934 Clinton, IA 52733-2934

Re: Your Recipient: Your Claim No.: Date of Loss: My Client: Our File No.:

Dear ______:

I left a voice message for you on May 17, 2019. As a follow up thereto, please be advised that the insurance carrier for the trucking company of the third-party tortfeasor has gone bankrupt and into liquidation. I have been exploring to see what recovery I can obtain directly from the trucking company______, in light of there being no insurance coverage. At this point, the prospects look bleak. Based on my conversations with opposing counsel, I would not expect to receive a settlement offer in excess of $75,000.00.

Regardless, in order for me to get this case resolved I will need the worker’s compensation lien to be reduced. I would propose a three-way split among the attorney’s fees, worker’s compensation lien, and client recovery.

Please let me know if your client would be willing to agree to such a proposal, which would be helpful for me in attempting to negotiate a settlement that is agreeable to my client. Please note that my client is prepared to walk away from settlement altogether if it will not net in an amount of at least one-third of the total settlement amount.

Please call me as soon as possible to discuss this matter.

Respectfully,

Isaac A. Hof

IAH:mlh cc: Client August 20, 2019

Claims Investigation Agent Pennsylvania Dept. of Human Services Division of Third-Party Liability P. O. Box 8486 Harrisburg, PA 17105-8486

Re: Beneficiary: CIS No.: Incident Date: Our File No.:

Dear Sir/Madam:

As you may recall, our office has been retained to represent the interests of CLIENT with regard to injuries she sustained in a motor vehicle accident which occurred on DATE. We have resolved CLIENT’s third-party claim in principle. The last correspondence received from you indicated an outstanding lien as of July 19, 2019 in the amount of $725.17.

I am respectfully requesting that the Department reduce its lien by the amount of attorney’s fees (35%). I have included herein a copy of our firm’s Contingency Fee Agreement and proposed Settlement & Distribution Sheet.

Thank you for your immediate attention to this request. I look forward to receiving the Department’s final lien documentation within the next twenty (20) days.

Respectfully,

Isaac A. Hof

IAH:mlh Enclosures

May 29, 2019

Via Certified and USPS First Class Mail Hartford Life & Accident Ins. Co. ATTENTION: SUBROGATION DEPT. P. O. Box 14772 Lexington, KY 40512

Re: Plan Name: Account No.: Claimant: Date of Loss: Our File No.:

Dear Sir/Madam:

Please be advised that we have been retained to represent CLIENT with regard to injuries she sustained in a motor vehicle accident which occurred on DATE. We have sent you several letters prior to this correspondence requesting your position on whether Hartford will be asserting a subrogated lien with regard to this matter. Despite our several, prior requests, we have heard nothing from you. At this point, unless I hear within ten (10) business days from the date of this letter, I will infer that no subrogation lien is being asserted. Please be further advised that I have reached a settlement in principle with the third-party insurance carrier to resolve CLIENT’s claim for the total policy limits available. Your lien will not be protected unless I hear from you within 10 days from the date of this letter.

Respectfully,

Isaac A. Hof

IAH:mlh

Capital Blue Cross Attention: Subrogation Department P. O. Box 211457 Eagan, MN 55121

Re: Your Insured: I.D. No.: Group No.: Claimant: Date of Loss: Our File No.:

Dear Sir/Madam:

Please be advised that we have been retained to represent the interests of CLIENT with regard to injuries sustained by CLIENT in a slip and fall incident which occurred on DATE.

Please advise if Capital Blue Cross will be asserting a subrogated lien with regard to this matter. Thank you for your attention to the above. If you have any questions, please do not hesitate to contact my office.

Respectfully,

Isaac A. Hof

IAH:mlh cc: CLIENT

[NOTE: IF DO NOT HEAR FROM THEM IN 30 DAYS – SEND FOLLOW-UP LETTER STATING: If we do not hear from you in 10 days, we will assume you do not intend on pursuing a subrogated lien and we will have no further contact.] Date

CERTIFIED MAIL RETURN RECEIPT REQUESTED

(Name of Plan Administrator – should be set forth in SPD) Plan Administrator for Medical Plan Street Address City, State, Zip Code

Re: Our File:

Dear Mr./Ms:

This firm represents ************** with respect to injuries sustained in a motor vehicle accident that occurred on ********. Pursuant to (client’s name) right as a participant and beneficiary of the Plan, I am requesting that you provide me with copies of the following:

(1) Copies of the Summary Plan Description (SPD) and other Plan Documents relating to my health insurance coverage for the years , , , and . (year preceding date of injury through current year); and (2) Administrative Services Contract between (Employer/Plan) and (Plan Insurer(s)/Claims Administrator) for the years , , , and . (year preceding date of injury through current year); and (3) Copies of all contracts including, but not limited to: Insurance contracts, Stop Loss Contracts, Health Insurance Contracts, Insurance Intermediary Services Contracts, and Administrative Services Contracts related to Medical Plan serving (insert name of state or region encompassing client) participants for the years , , , and . (year preceding date of injury through current year); and (4) Amendments to the Plan Documents for Medical Plan (including, but not limited to the Summary Plan Description) for the years , , , and . (year preceding date of injury through current year); and (5) C opies of the SMM (Summary of Material Modifications) statements for the years , , , and . (year preceding date of injury through current year); and (6) C opies of form 5500, including all attached schedules, filed with the U.S. Department of Labor for the years , , , and . (year preceding date of injury through current year).

Please provide the requested information within 30 days in accordance with 29 U.S.C. Section 1024(b)(4). Please be advised that 29 U.S.C. §1132(c)(1)(b), establishes a $110.00 per day fine for noncompliance with the request of the above-referenced documentation.

Please be further advised that as counsel for the beneficiary, ***********, the request for the above-referenced information is being made on behalf of *************, as plan beneficiary.

Thank you for your attention. Should you have any questions, please do not hesitate to contact me.

Respectfully,

Christopher M. Reid CMR:mrw Annual Return/Report of Employee Benefit Plan OMB Nos. 1210-0110 Form 5500 1210-0089 This form is required to be filed for employee benefit plans under sections 104 Department of the Treasury and 4065 of the Employee Retirement Income Security Act of 1974 (ERISA) and Internal Revenue Service sections 6057(b) and 6058(a) of the Internal Revenue Code (the Code). 2018 Department of Labor  Complete all entries in accordance with Employee Benefits Security Administration the instructions to the Form 5500. Pension Benefit Guaranty Corporation This Form is Open to Public Inspection Part I Annual Report Identification Information For calendar plan year 2018 or fiscal plan year beginning and ending X a multiemployer plan X a multiple-employer plan (Filers checking this box must attach a list of A This return/report is for: participating employer information in accordance with the form instructions.) X a single-employer plan X a DFE (specify) _C_

B This return/report is: X the first return/report X the final return/report X an amended return/report X a short plan year return/report (less than 12 months) C If the plan is a collectively-bargained plan, check here......  X

D Check box if filing under: X Form 5558 X automatic extension X the DFVC program X special extension (enter description) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE Part II Basic Plan Information—enter all requested information 1a Name of plan 1b Three-digit plan ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI number (PN)  001 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 1c Effective date of plan YYYY-MM-DD 2a Plan sponsor’s name (employer, if for a single-employer plan) 2b Employer Identification Mailing address (include room, apt., suite no. and street, or P.O. Box) Number (EIN) City or town, state or province, country, and ZIP or foreign postal code (if foreign, see instructions) 012345678 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 2c Plan Sponsor’s telephone D/B/A ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI number ABCDEFGHI 0123456789 c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 2d Business code (see 123456789 ABCDEFGHI ABCDEFGHI ABCDE instructions) 123456789 ABCDEFGHI ABCDEFGHI ABCDE 012345 CITYEFGHI ABCDEFGHI AB, ST 012345678901 UK

Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established. Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including accompanying schedules, statements and attachments, as well as the electronic version of this return/report, and to the best of my knowledge and belief, it is true, correct, and complete.

SIGN SAMPLEYYYY-MM-DD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE HERE Signature of plan administrator Date Enter name of individual signing as plan administrator

SIGN YYYY-MM-DD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE HERE Signature of employer/plan sponsor Date Enter name of individual signing as employer or plan sponsor

SIGN YYYY-MM-DD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE HERE Signature of DFE Date Enter name of individual signing as DFE For Paperwork Reduction Act Notice, see the Instructions for Form 5500. Form 5500 (2018) v. 171027 Form 5500 (2018) Page 2 3a Plan administrator’s name and address X Same as Plan Sponsor 3b Administrator’s EIN 012345678 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 3c Administrator’s telephone c/o ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI number 123456789 ABCDEFGHI ABCDEFGHI ABCDE 0123456789 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITYEFGHI ABCDEFGHI AB, ST 012345678901 UK 4 If the name and/or EIN of the plan sponsor or the plan name has changed since the last return/report filed for this plan, 4b EIN012345678 enter the plan sponsor’s name, EIN, the plan name and the plan number from the last return/report: a Sponsor’s name 4d PN c Plan Name 012

5 Total number of participants at the beginning of the plan year 5 123456789012 6 Number of participants as of the end of the plan year unless otherwise stated (welfare plans complete only lines 6a(1), 6a(2), 6b, 6c, and 6d).

a(1) Total number of active participants at the beginning of the plan year ...... 6a(1)

a(2) Total number of active participants at the end of the plan year ...... 6a(2)..

b Retired or separated participants receiving benefits...... 6b 123456789012

c Other retired or separated participants entitled to future benefits ...... 6.....c 123456789012

d Subtotal. Add lines 6a(2), 6b, and 6c...... 6d 123456789012

e Deceased participants whose beneficiaries are receiving or are entitled to receive benefits...... 6e 123456789012

f Total. Add lines 6d and 6e...... 6f 123456789012

g Number of participants with account balances as of the end of the plan year (only defined contribution plans complete this item) ...... 6g 123456789012

h Number of participants who terminated employment during the plan year with accrued benefits that were less than 100% vested ...... 6h.... 123456789012 7 Enter the total number of employers obligated to contribute to the plan (only multiemployer plans complete this item) ...... 7 8a If the plan provides pension benefits, enter the applicable pension feature codes from the List of Plan Characteristics Codes in the instructions:

b If the plan provides welfare benefits, enter the applicable welfare feature codes from the List of Plan Characteristics Codes in the instructions:

9a Plan funding arrangement (check all that apply) 9b Plan benefit arrangement (check all that apply) (1) X Insurance SAMPLE(1) X Insurance (2) X Code section 412(e)(3) insurance contracts (2) X Code section 412(e)(3) insurance contracts (3) X Trust (3) X Trust (4) X General assets of the sponsor (4) X General assets of the sponsor 10 Check all applicable boxes in 10a and 10b to indicate which schedules are attached, and, where indicated, enter the number attached. (See instructions)

a Pension Schedules b General Schedules (1) X R (Retirement Plan Information) (1) X H (Financial Information) (2) X I (Financial Information – Small Plan) (2) X MB (Multiemployer Defined Benefit Plan and Certain Money (3) X A Purchase Plan Actuarial Information) - signed by the plan ___ (Insurance Information) actuary (4) X C (Service Provider Information)

(3) X SB (Single-Employer Defined Benefit Plan Actuarial (5) X D (DFE/Participating Plan Information) Information) - signed by the plan actuary (6) X G (Financial Transaction Schedules)

Form 5500 (2018) Page 3

Part III Form M-1 Compliance Information (to be completed by welfare benefit plans) 11a If the plan provides welfare benefits, was the plan subject to the Form M-1 filing requirements during the plan year? (See instructions and 29 CFR 2520.101-2.) ...... ………..…. X Yes X No

If “Yes” is checked, complete lines 11b and 11c.

11b Is the plan currently in compliance with the Form M-1 filing requirements? (See instructions and 29 CFR 2520.101-2.) ……..... X Yes X No 11c Enter the Receipt Confirmation Code for the 2018 Form M-1 annual report. If the plan was not required to file the 2018 Form M-1 annual report, enter the Receipt Confirmation Code for the most recent Form M-1 that was required to be filed under the Form M-1 filing requirements. (Failure to enter a valid Receipt Confirmation Code will subject the Form 5500 filing to rejection as incomplete.)

Receipt Confirmation Code______

SAMPLE

SCHEDULE A Insurance Information OMB No. 1210-0110 (Form 5500)

Department of the Treasury This schedule is required to be filed under section 104 of the Internal Revenue Service Employee Retirement Income Security Act of 1974 (ERISA). 2018 Department of Labor Employee Benefits Security Administration  File as an attachment to Form 5500. Pension Benefit Guaranty Corporation  Insurance companies are required to provide the information This Form is Open to Public pursuant to ERISA section 103(a)(2). Inspection For calendar plan year 2018 or fiscal plan year beginning and ending A Name of plan B Three-digit ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE plan number (PN)  001 FGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI C Plan sponsor’s name as shown on line 2a of Form 5500 D Employer Identification Number (EIN) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 012345678 FGHI ABCDEFGHI Part I Information Concerning Insurance Contract Coverage, Fees, and Commissions Provide information for each contract on a separate Schedule A. Individual contracts grouped as a unit in Parts II and III can be reported on a single Schedule A. 1 Coverage Information:

(a) Name of insurance carrier ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

(e) Approximate number of Policy or contract year (c) NAIC (d) Contract or (b) EIN persons covered at end of code identification number (f) From (g) To policy or contract year

012345678 ABCDE ABCDE0123456789 1234567 YYYY-MM-DD YYYY-MM-DD

2 Insurance fee and commission information. Enter the total fees and total commissions paid. List in line 3 the agents, brokers, and other persons in descending order of the amount paid. (a) Total amount of commissions paid (b) Total amount of fees paid 123456789012345 123456789012345

3 Persons receiving commissions and fees. (Complete as many entries as needed to report all persons). (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901

(b) Amount of sales and base Fees and other commissions paid commissions paid (c) Amount (d) Purpose (e) Organization code -123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI SAMPLEABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Schedule A (Form 5500) 2018 Page 2 – 1 x

(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 Fees and other commissions paid (e) (b) Amount of sales and base Organization commissions paid (c) Amount (d) Purpose code -123456789012345 -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901 Fees and other commissions paid (e) (b) Amount of sales and base Organization commissions paid (c) Amount (d) Purpose code -123456789012345 -123456789012345SAMPLE ABCDEFGHI ABCDEFGHI ABCDEFGHI 1 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Part II Investment and Annuity Contract Information Where individual contracts are provided, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report. 4 Current value of plan’s interest under this contract in the general account at year end ...... 4 123456789012345 5 Current value of plan’s interest under this contract in separate accounts at year end ...... 5 123456789012345 6 Contracts With Allocated Funds: a State the basis of premium rates 

b Premiums paid to carrier ...... 6b -123456789012345 c Premiums due but unpaid at the end of the year ...... 6c -123456789012345 d If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or 6d -123456789012345 retention of the contract or policy, enter amount......

Specify nature of costs 

e Type of contract: (1) X individual policies (2) X group deferred annuity (3) X other (specify) 

f If contract purchased, in whole or in part, to distribute benefits from a terminating plan, check here  X X 7 Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts) a Type of contract: (1) X deposit administration (2) X immediate participation guarantee X (4) X other  (3) guaranteed investment

b Balance at the end of the previous year ...... 7b 123456789012345 c Additions: (1) Contributions deposited during the year ...... 7c(1) -123456789012345 (2) Dividends and credits ...... 7c(2) -123456789012345 (3) Interest credited during the year ...... 7c(3) -123456789012345 (4) Transferred from separate account...... 7c(4)... -123456789012345 (5) Other (specify below) ...... 7c(5) -123456789012345 

(6)Total additions ...... 7c(6) 123456789012345 d Total of balance and additions (add lines 7b and 7c(6))...... 7d 123456789012345 e Deductions: (1) Disbursed from fund to pay benefits or purchase annuities during year 7e(1) -123456789012345 (2) Administration charge made by carrier ...... 7e(2) -123456789012345 (3) Transferred to separate account ...... 7e(3) -123456789012345 (4) Other (specify below) ...... 7e(4) -123456789012345  SAMPLE

(5) Total deductions ...... 7e(5) 123456789012345 f Balance at the end of the current year (subtract line 7e(5) from line 7d) ...... 7f 123456789012345 Schedule A (Form 5500) 2018 Page 4

Part III Welfare Benefit Contract Information If more than one contract covers the same group of employees of the same employer(s) or members of the same employee organizations(s), the information may be combined for reporting purposes if such contracts are experience-rated as a unit. Where contracts cover individual employees, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report. 8 Benefit and contract type (check all applicable boxes) a X Health (other than dental or vision) b X Dental c X Vision d X Life insurance e X Temporary disability (accident and sickness) f X Long-term disability g X Supplemental unemployment h X Prescription drug i X Stop loss (large deductible) j X HMO contract k X PPO contract l X Indemnity contract m X Other (specify)  ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCKEFGHI ABCDEFGHI ABCDEFGHI ABCDE 9 Experience-rated contracts: a Premiums: (1) Amount received ...... 9a(1) -123456789012345 (2) Increase (decrease) in amount due but unpaid ...... 9a(2) -123456789012345 (3) Increase (decrease) in unearned premium reserve ...... 9a(3) -123456789012345 (4) Earned ((1) + (2) - (3)) ...... 9a(4) 123456789012345 b Benefit charges (1) Claims paid ...... 9b(1) -123456789012345 (2) Increase (decrease) in claim reserves ...... 9b(2)...... -123456789012345 (3) Incurred claims (add (1) and (2)) ...... 9b(3) 123456789012345 (4) Claims charged ...... 9b(4) 123456789012345 c Remainder of premium: (1) Retention charges (on an accrual basis) -- -123456789012345 (A) Commissions ...... 9c(1)(A).... -123456789012345 (B) Administrative service or other fees ...... 9c(1)(B)... -123456789012345 (C) Other specific acquisition costs ...... 9c(1)(C)...... -123456789012345 (D) Other expenses ...... 9c(1)(D) . -123456789012345 (E) Taxes ...... 9c(1)(E)...... -123456789012345 (F) Charges for risks or other contingencies ...... 9c(1)(F) -123456789012345 (G) Other retention charges ...... 9c(1)(G) -123456789012345 (H) Total retention ...... 9c(1)(H) 123456789012345 (2) Dividends or retroactive rate refunds. (These amounts were X paid in cash, or X credited.) ...... 9c(2) 123456789012345 d Status of policyholder reserves at end of year: (1) Amount held to provide benefits after retirement ...... 9d(1) 123456789012345 (2) Claim reserves ...... 9d(2) 123456789012345 (3) Other reserves...... 9d(3) 123456789012345 e Dividends or retroactive rate refunds due. (Do not include amount entered in line 9c(2).) ...... 9e 123456789012345 10 Nonexperience-rated contracts: a Total premiums or subscription charges paid to carrier ...... 10a. 123456789012345 b If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or - retention of the contract or policy, other than reported in Part I, line 2 above, report amount...... 10b 123456789012345 Specify nature of costs. ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHISAMPLE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

Part IV Provision of Information 11 Did the insurance company fail to provide any information necessary to complete Schedule A? ...... X Yes X No 12 If the answer to line 11 is “Yes,” specify the information not provided.  ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

SCHEDULE C Service Provider Information OMB No. 1210-0110 (Form 5500) 2018 Department of the Treasury This schedule is required to be filed under section 104 of the Employee Internal Revenue Service Retirement Income Security Act of 1974 (ERISA). Department of Labor Employee Benefits Security Administration  File as an attachment to Form 5500. This Form is Open to Public Inspection. Pension Benefit Guaranty Corporation For calendar plan year 2018 or fiscal plan year beginning and ending A Name of plan B Three-digit ABCDEFGHI plan number (PN)  001

C Plan sponsor’s name as shown on line 2a of Form 5500 D Employer Identification Number (EIN) ABCDEFGHI 012345678

Part I Service Provider Information (see instructions)

You must complete this Part, in accordance with the instructions, to report the information required for each person who received, directly or indirectly, $5,000 or more in total compensation (i.e., money or anything else of monetary value) in connection with services rendered to the plan or the person's position with the plan during the plan year. If a person received only eligible indirect compensation for which the plan received the required disclosures, you are required to answer line 1 but are not required to include that person when completing the remainder of this Part.

1 Information on Persons Receiving Only Eligible Indirect Compensation a Check "Yes" or "No" to indicate whether you are excluding a person from the remainder of this Part because they received only eligible indirect compensation for which the plan received the required disclosures (see instructions for definitions and conditions)...... X Yes X No b If you answered line 1a “Yes,” enter the name and EIN or address of each person providing the required disclosures for the service providers who received only eligible indirect compensation. Complete as many entries as needed (see instructions).

(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

(b) Enter name and EIN orSAMPLE address of person who provided you disclosures on eligible indirect compensation

(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

For Paperwork Reduction Act Notice, see the Instructions for Form 5500. Schedule C (Form 5500) 2018 v.180523

Schedule C (Form 5500) 2018 Page 2- 1 x

(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

SAMPLE

(b) Enter name and EIN or address of person who provided you disclosures on eligible indirect compensation

Schedule C (Form 5500) 2018 Page 3 - 1 x

2. Information on Other Service Providers Receiving Direct or Indirect Compensation. Except for those persons for whom you answered “Yes” to line 1a above, complete as many entries as needed to list each person receiving, directly or indirectly, $5,000 or more in total compensation (i.e., money or anything else of value) in connection with services rendered to the plan or their position with the plan during the plan year. (See instructions).

(a) Enter name and EIN or address (see instructions)

(b) (c) (d) (e) (f) (g) (h) Service Relationship to Enter direct Did service provider Did indirect compensation Enter total indirect Did the service Code(s) employer, employee compensation paid receive indirect include eligible indirect compensation received by provider give you a organization, or by the plan. If none, compensation? (sources compensation, for which the service provider excluding formula instead of person known to be enter -0-. other than plan or plan plan received the required eligible indirect an amount or a party-in-interest sponsor) disclosures? compensation for which you estimated amount? answered “Yes” to element (f). If none, enter -0-.

ABCDEFGHI 123456789012 123456789012345 ABCDEFGHI 345 Yes X No X Yes X No X Yes X No X ABCD

(a) Enter name and EIN or address (see instructions)

SAMPLE

Schedule C (Form 5500) 2018 Page 4 - 1 x

Part I Service Provider Information (continued) 3. If you reported on line 2 receipt of indirect compensation, other than eligible indirect compensation, by a service provider, and the service provider is a fiduciary or provides contract administrator, consulting, custodial, investment advisory, investment management, broker, or recordkeeping services, answer the following questions for (a) each source from whom the service provider received $1,000 or more in indirect compensation and (b) each source for whom the service provider gave you a formula used to determine the indirect compensation instead of an amount or estimated amount of the indirect compensation. Complete as many entries as needed to report the required information for each source. (a) Enter service provider name as it appears on line 2 (b) Service Codes (c) Enter amount of indirect (see instructions) compensation

(d) Enter name and EIN (address) of source of indirect compensation (e) Describe the indirect compensation, including any formula used to determine the service provider’s eligibility for or the amount of the indirect compensation.

(a) Enter service provider name as it appears on line 2 (b) Service Codes (c) Enter amount of indirect (see instructions) compensation

SAMPLE

Schedule C (Form 5500) 2018 Page 5 - 1 x

Part II Service Providers Who Fail or Refuse to Provide Information 4 Provide, to the extent possible, the following information for each service provider who failed or refused to provide the information necessary to complete this Schedule. (a) Enter name and EIN or address of service provider (see (b) Nature of (c) Describe the information that the service provider failed or refused to instructions) Service provide Code(s) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 10 11 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 12 13 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 1234567890 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

(a) Enter name and EIN or address of service provider (see (b) Nature of (c) Describe the information that the service provider failed or refused to instructions) Service provide Code(s) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 10 11 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 12 13 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 1234567890 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

(a) Enter name and EIN or address of service provider (see (b) Nature of (c) Describe the information that the service provider failed or refused to instructions) Service provide Code(s) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 10 11 12 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 13 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 1234567890 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

(a) Enter name and EIN or address of service providerSAMPLE (see (b) Nature of (c) Describe the information that the service provider failed or refused to instructions) Service provide Code(s) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 10 11 12 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 13 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 1234567890 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

(a) Enter name and EIN or address of service provider (see (b) Nature of (c) Describe the information that the service provider failed or refused to instructions) Service provide Code(s) ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 1234567890 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE Schedule C (Form 5500) 2018 Page 6 - 1 x

Part III Termination Information on Accountants and Enrolled Actuaries (see instructions) (complete as many entries as needed) a Name: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD b EIN: 123456789 c Position: ABCDEFGHI ABCDEFGHI ABCD d Address: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD e Telephone: 1234567890 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD Explanation: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI a Name: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD b EIN: 123456789 c Position: ABCDEFGHI ABCDEFGHI ABCD d Address: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD e Telephone: 1234567890 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD Explanation: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI a Name: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD b EIN: 123456789 c Position: ABCDEFGHI ABCDEFGHI ABCD d Address: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD e Telephone: 1234567890 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD Explanation: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI a Name: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD b EIN: 123456789 c Position: ABCDEFGHI ABCDEFGHI ABCD d Address: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD e Telephone: 1234567890 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD Explanation: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHISAMPLE ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI a Name: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD b EIN: 123456789 c Position: ABCDEFGHI ABCDEFGHI ABCD d Address: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD e Telephone: 1234567890 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD Explanation: ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI