"Agreement for Confirmation of Client Signed Authorization and Transfer and Use of Information" - Montana

Agreement for Confirmation of Client Signed Authorization and Transfer and Use of Information is a legal document that was released by the Montana Department of Labor and Industry - a government authority operating within Montana.

Form Details:

  • Released on April 1, 2021;
  • The latest edition currently provided by the Montana Department of Labor and Industry;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Labor and Industry.

ADVERTISEMENT
ADVERTISEMENT

Download "Agreement for Confirmation of Client Signed Authorization and Transfer and Use of Information" - Montana

Download PDF

Fill PDF online

Rate (4.6 / 5) 7 votes
AGREEMENT FOR CONFIRMATION OF CLIENT SIGNED AUTHORIZATION AND
TRANSFER AND USE OF INFORMATION
Section 1. Parties to the Agreement.
1.1
This agreement for confirmation of client signed authorization and transfer and use of
information (“this Agreement”) is entered into by and between the Montana Department of
Labor and Industry, Unemployment Insurance Division, Contributions Bureau and
, a Third Party Administrator (“the TPA”).
Section 2. Purpose of the Agreement.
2.1
The TPA is a business that is authorized to act on behalf of it clients to represent their
interests interacting with the Contributions Bureau. The purpose of this Agreement is to ensure
that the TPA has on file a signed authorization from each client it represents that authorizes the
TPA to pay and file Montana unemployment insurance contribution taxes to the Contributions
Bureau and to receive confidential tax account information from the Contributions Bureau.
2.2
This Agreement shall serve to permit the TPA to participate in the Fiscal Rate Exchange
Program and to discuss bulk-filing issues with Contributions personnel.
Section 3. Limited license granted.
3.1
The information transfer that is the subject of this Agreement creates only a limited
license for the use of the information transferred, and does not give the TPA any ownership
interests in the information itself. The license granted extends only to the TPA’s use as
described in this Agreement. The TPA is prohibited from granting access to the information
transferred by this Agreement to any other persons that are not the employees of TPA or the
represented client without the express, written consent of the Contributions Bureau.
3.2
The information that is transferred pursuant to this Agreement may only be used for the
expressed purpose as originally intended.
3.3
The TPA may not disclose the information transferred pursuant to this Agreement to any
non-employee agent of the TPA without the express, written consent of the Contributions
Bureau.
Section 4. Description of information being transferred.
4.1
The information being transferred pursuant to this Agreement consists of confidential
information necessary to assist the TPA with client billing and general unemployment insurance
tax account questions and validation in connection with the payroll reports that the TPA files on
its client’ behalf.
4.2
The information being transferred pursuant to this Agreement will include Contribution
tax rates and general data regarding the bulk filing and payment of UI quarterly reports.
Section 5. Duties.
5.1
The TPA agrees to provide a copy of a client’s authorization, by mail, fax, or secure
electronic submission within 24 hours upon request by the Contributions Bureau.
Page 1 of 5
UI_TPA_MOU Rev. April/2021
AGREEMENT FOR CONFIRMATION OF CLIENT SIGNED AUTHORIZATION AND
TRANSFER AND USE OF INFORMATION
Section 1. Parties to the Agreement.
1.1
This agreement for confirmation of client signed authorization and transfer and use of
information (“this Agreement”) is entered into by and between the Montana Department of
Labor and Industry, Unemployment Insurance Division, Contributions Bureau and
, a Third Party Administrator (“the TPA”).
Section 2. Purpose of the Agreement.
2.1
The TPA is a business that is authorized to act on behalf of it clients to represent their
interests interacting with the Contributions Bureau. The purpose of this Agreement is to ensure
that the TPA has on file a signed authorization from each client it represents that authorizes the
TPA to pay and file Montana unemployment insurance contribution taxes to the Contributions
Bureau and to receive confidential tax account information from the Contributions Bureau.
2.2
This Agreement shall serve to permit the TPA to participate in the Fiscal Rate Exchange
Program and to discuss bulk-filing issues with Contributions personnel.
Section 3. Limited license granted.
3.1
The information transfer that is the subject of this Agreement creates only a limited
license for the use of the information transferred, and does not give the TPA any ownership
interests in the information itself. The license granted extends only to the TPA’s use as
described in this Agreement. The TPA is prohibited from granting access to the information
transferred by this Agreement to any other persons that are not the employees of TPA or the
represented client without the express, written consent of the Contributions Bureau.
3.2
The information that is transferred pursuant to this Agreement may only be used for the
expressed purpose as originally intended.
3.3
The TPA may not disclose the information transferred pursuant to this Agreement to any
non-employee agent of the TPA without the express, written consent of the Contributions
Bureau.
Section 4. Description of information being transferred.
4.1
The information being transferred pursuant to this Agreement consists of confidential
information necessary to assist the TPA with client billing and general unemployment insurance
tax account questions and validation in connection with the payroll reports that the TPA files on
its client’ behalf.
4.2
The information being transferred pursuant to this Agreement will include Contribution
tax rates and general data regarding the bulk filing and payment of UI quarterly reports.
Section 5. Duties.
5.1
The TPA agrees to provide a copy of a client’s authorization, by mail, fax, or secure
electronic submission within 24 hours upon request by the Contributions Bureau.
Page 1 of 5
UI_TPA_MOU Rev. April/2021
5.2
The TPA will notify the Contributions Bureau immediately if a client authorizes the TPA
to receive confidential information on its client’s behalf or if a client withdraws its authorization.
5.3
The Contributions Bureau agrees to rely on this certification to periodically provide
current unemployment insurance experience (tax) rates, verify state employer identification
numbers assigned, and notify the TPA of errors or possible discrepancies in bulk filing files, at
such times in such formats as may be mutually agreed upon.
Section 6. Non-disclosure of personal identifiers.
6.1
To the extent that any of the information being transferred pursuant to this Agreement
includes or consists of personal identifiers (including, name and social security number), the
TPA agrees that it will take all necessary steps to protect that personal identifier information
from intentional or accidental disclosure to any person or entity not authorized by this
Agreement. Those steps must include, but are not limited to providing:
6.1.1 locked file cabinets or safes to store written copies of the information when that
information is not being actively used;
6.1.2 password protection for any information stored in an electronic database; and
6.1.3 training of those employees or agents with access to the information, concerning the
acceptable uses of the information, and the securing and safeguarding of that information.
6.1.4 information is not to be copied, removed, or stored outside of the TPA’s offices unless
there is a business requirement approved by the Contributions Bureau.
6.1.5 access is based on business requirements and limited solely to specifically authorized
TPA personnel.
6.2
The TPA acknowledges that it and its agents and employees may be subject to state
and/or federal civil and criminal penalties in the event it makes unauthorized disclosures of
legally protected information.
6.3
In the event of a breach of confidentiality or possible security breach, the TPA agrees to
notify the Internal Security officer of the Contributions Bureau within 24 hours of discovery of
the breach of confidentiality or possible security breach.
6.4
In the event a third party attempts to compel by way of legal process the disclosure of any
of the information that is being transferred pursuant to this Agreement, the TPA agrees to
immediately notify the Contributions Bureau of that fact. The TPA must reasonably cooperate
with the Contributions Bureau in the event the Contributions Bureau elects to resist that legal
compulsion. The TPA, however, is not required to (although it may do so at its own expense)
retain counsel to resist that legal compulsion, once the TPA has notified the Contributions
Bureau as provided by this paragraph.
6.5
The TPA agrees that it will maintain a system sufficient to allow an audit of the TPA's
compliance with the security requirements imposed by this Agreement and 20 CFR § 603. The
TPA agrees to cooperate with the Contributions Bureau in the performance of security audits
performed pursuant to 20 CFR § 603.
Section 7. Indemnity.
7.1
The TPA agrees to defend, indemnify and hold harmless the Contributions Bureau, the
Page 2 of 5
UI_TPA_MOU Rev. April/2021
Unemployment Insurance Division, the Department of Labor and Industry, and the State of
Montana from any claims arising out of the transfer of the information that is the subject of this
Agreement, or arising out of the use, misuse or disclosure by the TPA of that information.
7.2
The TPA agrees to indemnify the Contributions Bureau and the Department of Labor and
Industry for any losses or damages arising out of the TPA’s violation of any of the terms of this
Agreement.
Section 8. No warranty regarding the information.
8.1
Although the Contributions Bureau uses reasonable care in collecting the data or
information in its records, the Contributions Bureau makes no express or implied warranty of the
accuracy of the information that is being transferred to the TPA. The TPA acknowledges that it
takes the information “as is”, and that there is no express or implied warranty of accuracy or
fitness for any purpose associated with the use of the data or information.
Section 9. Term of the contract.
9.1
The term of this Agreement runs from the date this Agreement is executed until it is
terminated by either party per section 9.3.
9.2
In the event of a material breach of this Agreement, the Contributions Bureau may
terminate this Agreement immediately if the Contributions Bureau determines that the TPA has
violated its obligations under this Agreement, including failure to provide a copy of the
requested authorization form, unauthorized disclosure to other third parties, or failure to properly
secure confidential information.
9.3
Either the Contributions Bureau or the TPA may terminate this Agreement upon (sixty)
60 calendar days written notice to the other party.
9.4
The TPA agrees to maintain the confidentiality of the information transferred pursuant to
this Agreement after the termination of this Agreement.
Section 10. Entire document and modifications.
10.1
Except as provided by paragraph 10.2, this Agreement constitutes the entire agreement
between the Contributions Bureau and the TPA with respect to the verification of client
authorization and information transfer that is the subject of this Agreement. No other statements,
understandings or promises serve to modify or explain the terms of this Agreement.
10.2
Only a document or writing, specifically referred to and identified as an exhibit to this
Agreement, and attached as an exhibit to this Agreement, is incorporated by reference in this
Agreement. Such an exhibit does not need to be signed by the parties, but must be attached to
this Agreement at the time of signing by both parties.
10.3
This Agreement may not be modified, except in a writing signed by both parties.
Section 11. Good faith and further cooperation.
11.1
The parties agree to act in good faith with respect to one another in the performance of
this Agreement.
11.2
The parties agree to further cooperate as reasonably necessary to carry out the provisions
Page 3 of 5
UI_TPA_MOU Rev. April/2021
of this Agreement.
11.3
The parties designate the following individuals as their respective points of contact for
the purposes of communications regarding this Agreement:
11.3.1
For the Contributions Bureau:
Corena Benjamin
1315 Lockey
PO Box 6339
Helena MT 59604
406-444-0690
cbenjamin@mt.gov
11.3.2
For the TPA:
Representative name:
TPA business name:
Address:
City, state, zip:
Phone:
Email:
Section 12. Choice of law and venue.
12.1
The Contributions Bureau and the TPA agree that in the event of litigation concerning
the terms of this Agreement, this Agreement will be construed in accordance with Montana law
and venue will be in the First Judicial District of Montana, Lewis and Clark County.
Page 4 of 5
UI_TPA_MOU Rev. April/2021
Section 13. Execution of counterpart originals.
13.1
This Agreement will be executed in two counterpart originals, any and all of which are
to be deemed an “original” of this Agreement. The person executing this Agreement on behalf
of the TPA specifically represents to the Contributions Bureau that the person is authorized to act
on behalf of the TPA and to bind the TPA in contract.
Approved for the TPA:
by:_________________________________
date:_________________
(TPA authorized signature and title)
Approved for the Contributions Bureau:
by:_________________________________
date:_________________
(UI representative and title)
Page 5 of 5
UI_TPA_MOU Rev. April/2021
Page of 5