TEAMSTERS LOCAL 671
HEALTH SERVICES AND INSURANCE PLAN
18 Britton Drive
Bloomfield, CT 06002
CONSENT TO LIEN/REIMBURSEMENT AGREEMENT
1.I, ______[name]______, of ______[address]______, a covered Participant in the Teamsters Local 671 Health Services and Insurance Plan (“Plan”), do hereby acknowledge that the Plan specifically provides that no health benefits will be paid for any services required because of an illness, injury, or other condition which directly or indirectly is the result from an action or inaction ofa third party, including a work-related injury, illness or condition.
2.I understand that the Plan may advance the expenses for such coverage, if Iandmy Covered Dependent(s) (if my Covered Dependent(s) incurred the relevant injury, illness or condition) and my attorney and/or the attorney for my Covered Dependent(s), as the case may be, if an attorney has been retained, agree in writing to the terms stated below. In regard to a work-related injury, if I or my Covered Dependent(s) provide proof that the employer has denied liability.
3.By signing this statement, I agree, if the Plan advances benefits to me or my CoveredDependent(s) related to such injury, illness or other condition described above, the Plan shall have the right to recover the full amount of related expenses from any entity that is in receipt of the proceeds from any recoveries, settlements, awards or judgments that I or anyone acting on my behalf obtained from a third party or insurance carrier without reduction, deduction, offset or adjustments of any kindwhatsoever; specifically:
a.The Plan shall have the right to recover the full amount of related expenses without deductions for any expenses incurred to secure such recoveries, settlements, awards or judgments (including but not limited to attorneys’ fees); and
b.The Plan shall have the right to recover the full amount of related expenses regardless of the level of my recovery or the recovery of my Covered Dependent(s), even if I and/or my Covered Dependent(s) are not considered to have been made whole.
4.By signing this statement, I agree, that I and my agents, assigns, heirs, trustees and attorneys and/or my Covered Dependant(s) and the agents, assigns, heirs, trustees and attorneys thereof will reimburse the Plan the full amount of its related expenses without deductions or adjustments of any kind from the proceeds of any recovery in any action, claim or suit for damages of any kind related to such injury, illness or other condition, including, but not limited to homeowners insurance and underinsured motorist coverage.I agree to reimburse to the Plan the full amount of any benefits paid by the Plan, according to the Plan’s rights of recovery outlined above, unless the Trustees approve in writing other terms of reimbursement. I agree to reimburse the Plan within thirty (30) days of the receipt of such proceeds or I and my agents, assigns, heirs, trustees and attorneys and/or my Covered Dependant(s) and the agents, assigns, heirs, trustees and attorneys thereof will be liable for one percent (1%) interest compounded monthly on the amount owed commencing on the 31st day following the receipt of such proceeds. I and my agents, assigns, heirs, trustees and attorneys and/or my Covered Dependant(s) and the agents, assigns, heirs, trustees and attorneys thereof will be liable for all costs incurred by the Plan to collect such reimbursement, including but not limited to reasonable attorneys’ fees and the costs of suit.
If the Plan so requests, I agree to assign to the Plan any and all rights to payment of any such proceeds that may be assigned, up to the total amount of the benefits provided to me and/or my Covered Dependent(s) related to such illness, injury or condition. I agree that the Plan has the full power and authority, for its own use and benefit, to file, prosecute, withdraw, or settle such a claim as fully and for all intents and purposes, as I might or could do if this assignment were not made.
5.Date of Accident or Incident:______
Nature of Illness, Injury or Other Condition: ______
Description of Accident or Illness: ______
6.I agree that I will promptly notify the Plan when I or my Covered Dependent(s) make any claim (including a claim made under state Workers Compensation law or any similar state or federal statute, or any insurance policy, including the uninsured or underinsured motorist provisions of any automobile insurance policy) or bring any actionor suit for damages related to such injury, illness or other condition.
7.In order to secure the Plan’s rights of reimbursement outlined herein and in the Summary Plan Description, including the right to receive interest, costs or attorneys’ fees for which I or my Covered Dependent(s) may be liable, I acknowledge that the Plan shall have a lien against such proceeds to the maximum extent allowed by law. The Plan’s lien shall attach immediately upon receipt by me or my Covered Dependent(s) or by any attorney, agent, assign, heir or trustee. The Plan’s lien shall be discharged only by written release executed by the Trustees.
8.The name, address and signature of the attorney, if I or my Covered Dependent(s) have already retained an attorney, is set forth below. I agree to promptly notify the Plan if I or my Covered Dependent(s) retain an attorney in relation to this accident or incident after the execution of this agreement. If I or my Covered Dependent(s) have already retained an attorney, I agree to promptly notify the Plan if any new or different attorney is retained at a later time.
9.I irrevocably direct any attorney acting on my behalf or on the behalf of my Covered Dependent(s) to execute this agreement and promptly provide the Plan any and all requested information regarding such claim, action or suit or regarding insurance as requested. In any event, I agree that any attorney acting on my behalf or on the behalf of my Covered Dependent(s) in regard to a relevant claim shall be bound by this agreement, and irrevocably direct him or her to act in accordance with its terms, to hold the proceeds from any recovery, to the full of extent of the Plan’s lien, in constructive trust for the Plan and to honor the Plan’s lien and pay over to the Plan so much of such proceeds as are required to satisfy the Plan’s lien.
10.Upon demand by the Plan, I and/or my Covered Dependents agree to execute any instruments and papers, furnish information and assistance, give appropriate notice, and take any other necessary and related action as the Plan may require to facilitate its recovery, including the prompt application to the Probate Court having jurisdiction, to be appointed guardian and/or conservator of the estate and property of any Covered Dependent(s) of mine to whom or upon whose behalf the Plan has advanced benefits and to furnish the Plan with certification of such appointment. If any other person, at any time makes such application, I will immediately notify the Plan. In any event, I agree to petition such Probate Court to approve and ratify this agreement and to require any guardian or conservator to become party hereto.
11.I acknowledge that the Plan is a self-insured, ERISA-qualified fund exempt from Connecticut General Statute Sec. 52-225c, as amended, because it is preempted by ERISA. I acknowledge that this agreement is enforceable pursuant to the terms of ERISA.
12.I hereby state that I have not given any release or discharge of my right to recover from any other party for the expenses and charges which the Plan has or will pay under this agreement and that I have and will not do anything to prejudice such rights of recovery.
13.I understand and agree that if my Covered Dependent(s) and I do not comply with the terms of this agreement and as a result the Plan is not reimbursed for the benefits extended in reliance on this agreement, the Plan may withhold future benefit payments to me or my Covered Dependents.
ARE YOU SEEKING REIMBURSEMENT FROM A THIRD PARTY? Yes No
Attorney’s Name:______
Attorney’s Signature:
Address:______
Telephone Number:______Fax Number:
Email Address:
Participant’s Address:______
Telephone Number:______Fax Number:
Email Address:
______
Participant Signature
______
Date signed
______
Name of Dependent
______
Dependent Signature, if over 16 years of age
______
Date signed
State of______
Countyof______
On the ______day of ______, 20___, before me came ______to me known to be the person described herein and who executed the foregoing statement, and they duly acknowledged to me that they executed the same as their free act and deed for the purposes therein contained. In witness whereof, I hereunto set my hand.
______
(Notary Public)
SEAL REQUIRED
s:\gsc\teamsters local 671 hsip\teamsters 671 hsip - general\2013\misclien reimb agreement130215.doc
1