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HomeMy WebLinkAboutExhibit 5MasterCoverage Waiver Claim Form for MasterCard Corporate Payment Solutions' Please complete Sections 1-4 of this form, Attach copies of any supporting documentation. Return the claim form and all supporting documents to your financial institution within 90 days of the card cancellation date. Sertion one: Company Information Compa2Name - Contact Person and Title Fax—, ,_�.--•-_-----._+_. Check one ❑ Corporation ❑ Proprietorship ❑ Partnership ❑ other (specify) Cii�__..�__ _ �._____ _ __�._ State How many MasterCard Corporate Payment Solutions cards are issued to your Company? ❑ 1 (lnefigibie for coverage) ❑ 7-4 ❑ 5 or more Who is billed on this account? (Check one) ❑ Cardholder ❑ Company Type of Liability in Card Agreement (Check one) ❑ individual ❑ Corporate ❑ Joint & Several Type of Corporate Payment Solutions card (Check one) ❑ MasterCard BusinessCard• Card ❑ MasterCard Public Sector Travel Card' ❑ MasterCard Executive BusinessCard Card° ❑ MasterCard Public Sector Purchasing Card, © Debit MasterCard BusinessCard" Card ❑ MasterCard Public Sector Fleet Card' ❑ MasterCard Small Business Multi Card?m ❑ MasterCard Public Sector Multi Card* ❑ MasterCard Corporate Card" ❑ MasterCard Government Travel Card' ❑ MasterCard Corporate Executive Card* © MasterCard Government Purchasing Card* ❑ MasterCard Corporate Purchasing Card' ❑ MasterCard Government Fleet Card' ❑ MasterCard Corporate Fleet Card* ❑ MasterCard Government integrated Card" (2 MasterCard Corporate Multi Card Card' I • Poof • Cardholder Name (Last First. Middle) _ Social Securi� it _ - - - - _ - - Employee Position _�_A___.____.�•�.V_ Empiioyee Birth bate rrfdd/yy_ State_-- Zip Last Known Home Last Known Business Address State --- Z -^ Last known Business Telephone Number Last aay-of Employment* (mm/dd/yy} MasterCard Corporate Payment Solutions Card Account Number Date card was cancelled mmldd Was the card retrieved from the employee? Was the card cut in half and returned to us? ❑ Yes ❑ No ❑ Yes ❑ No -[be Program Underwriter resertmes (be rtgbi to request aocumeniadion to confirm the employees date of tvr•minauun, ® 2005 MasterCard Internacional Incorporated !in Thmp- Wiivahlr- Total amount of waivable charges claimed $ Please attach copies of documentation indicating which charges are wafvable as outlined in the "Description of Coverage" section depending on the type of liability agreement. A. Individual Liability e. Corporate Liability payroll documentation. Evidence • Billing statements • Billing statement with indication should incorporate the following • Evidence of reimbursement to and explanation of charges that information: check number, date include any or all of the following: did not directly or indirectly of reimbursement, and amount of copy of check, employee expense benefit the company. reimbursement. report, relevant account payable or C. Joint & Several Liability OR payroll documentation. Evidence . Evidence of reimbursement to • eilfing statement with indication should incorporate the following include any or all of the following: and explanation of charges that information: check number, date copy of check, employee expense did not directly or indirectly of reimbursement, and amount of report, relevant account payable or benefit the company. reimbursement. in the event the company has Joint & Several or Corporate Liability, if the Company recovers any amounts for unauthorized charges claimed from any source, the Company will remit all such amounts to the Financial Institution. The Company agrees to assign any rights it may have to collect unauthorized charges from the cardholder, to the MasterCoverage Program Underwriter. I, the undersigned, an officer of the Company listed above being duly sworn, depose and say that the answers provided above are true and complete to the best of my knowledge. The cardholder was an employee of our company, and not a partner, owner, principal shareholder owning more than 5% of the company's shares, or an elected director. I have reviewed the MasterCard Corporate Payment Solutions card account described above and hereby state that the charges being claimed under MasterCoverage (remaining unpaid on this account) qualify as waivabie charges as described on the attached billing statements in accordance with the MasterCoverage guidelines. The Cardholder has been advised that his/her MasterCard Corporate Payment Solutions card account has been cancelled and that all outstanding charges must be paid by himiher immediately, I further state that the cardholder is no longer employed by the company. Company Name y(signature) Print Name Title Have you induded the fo/fowm_q supporting documents depending on type of liability? ► Copy of card cancellation confirmation letter, or printout of card cancellation screen • Copy of employee notification letter to cardholder • Copies of cardholder billing statements, with waivabie charges • Copies of expense reports or equivalent documentation, if applicable • Copies of any written correspondence to the cardholder requesting payment If the Financial Institution recovers any amount from the Cardholder or `Cope of reimbursement documentation, if applicable any other source with respect to waivabie charges, the Financial Copy of analysis used to determine the amount of charges Institution agrees to use these funds to reduce the wafvable charges which did not benefit the company, if applicable or the amount of any claim the Financial Institution files under MasterCoverage, or if the MasterCoverage claim has already been paid to the Financial Institution, the Financial Institution shall remit such amounts to the Program Underwriter for MasterCoverage. We agree to the assignment of collection rights to the MasterCoverage Program Underwriter, Print Name Title Month �� Year Card Cancellation Date Submit Claim Form and supporting docunientwdon: Masreri'oaerI'�ge PrOEMM Adirantstrntor 13.922 Denver W Pkwy BuLtding 54 Golden, CO 50901 nt (3 03) 2 71-2 44 7 Note.• Ai some tone, AdcuierCard and its Program Undenurtler- may request junkier documenlwion rqgarding piwf,bat The charges fn question ta°nefilied the company, Financial Insiflullons musl be able to identify and document cardholders on centrally Gilled accounts. O 2005 MaswrCard International Incorporated Nates MasterCard International J.raster[aM t 01do5 Ma61RCvd �Nernational Incorporated