Medicare Secondary Payer Statement Of Employer In Support Of Application For Small Employer Exception Page 3
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3Banyan Administrators, LLC
Managers for the CalCPA ProtectPlus Programs
1215 Manor Drive
Suite 200
Mechanicsburg, PA 17055
Re:
MSP Cover Letter and Statement of Employer
Dear Banyan Administrators, LLC:
We currently have ________ employees. Based on the information set forth in the attached
form we certify that we are not a firm with 20 or more employees within the meaning of
applicable regulations.
Kind regards,
__________________________________________
_____________________
Signature
Date
__________________________________________
Name
__________________________________________
Title
__________________________________________
______________________
Company
Tax ID
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Parent category: Medical