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<br />applicable schedules and will submit the filing using the Department <br />an authorization allowing MedSurety LLC submission and signature <br />rights on the EFAST2 System and/or the client will be responsible <br />for signing the form electronically using the EFAST2 system. If the <br />client authorizes MedSurety LLC to electronically sign and submit the <br />form on their behalf, the client must also provide MedSurety LLC a <br />hard copy of a reviewed and signed 5500 Form so that it may be <br />attached to the submission. <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Adopting Employer/Plan Administrator Authorized Representatives <br /> <br />Name: Signature: Title: Date: <br />Name: Signature: Title: Date: <br />Name: Signature: Title: Date: <br />Name: Signature: Title: Date: <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />MEDSURETY, LLC <br />24 <br />Administration Agreement (Non-ERISA) Exhibit <br />Business Associate Agreement <br /> <br />