Laserfiche WebLink
Ii TASC Retiree Billing Application <br />Follow these instructions for fast :uud clFciene processing of your Plan Application, <br />• Cliwna must coatpko: aft Semons. <br />• Picax print le fl-ty far fixing. <br />C:nnraa I ASC (m 2-SSS-595-2261) far .tisialmice will, the Plan Applkarisn. <br />Fa.¢ lv;ar eomPlru•d Plan Av licarion Awng wirh your lac to Cad •2-11.45S4 tit mail it to TASC, 2302 <br />pO Box:L4140. 41ad:i ,w Wl 537043L40. <br />(1)EMPLOYER/ADMINISTRATOR <br />a+:n.,rc Namc 1 ;w( (C _f i '1(lil'/� <br />i n <br />::mnpmty^!>,ex:(Fulllegain>me. indudiny :lhi if appliubl.) � <1.% - ...J(�%-r { ��1�-)!+ <br />C:onq+any PhvsirA Addm;5:n.t PO Boa} Ib' l � J !/19 Gg• `,- -ft 'nru. Zip <br />Aradiny:lJ.l:•x:—ifiiiaro,r from <br />Namc.. and ux (U 3J ufanp other asrnmen!•r ewnz,L'en:.milkd Campanile, amr arc Pamidpacing <br />E-nt2:1 A:wrcts —WA _`I'C <br />21wne Num6,:r/ 11 -'� / F>r Nurnbnr LF r 7 17 <br />Swiaa. Fc.1'MUD+_J�s—r Gf•li f � i AIC_SorSIC Code{Fum:Jnr. ifL.3 Fenn iiCU, iina 3,i) <br />Un you pima micresr i.. m ach.rbnsrnw' •J Yes C?1:.o ffy's. nna;ua a([n:plolep a�__ <br />If eon are s turrgne Cliznr aTASC. Fleas. nne which Beni v: O Fleails:nn (FSA) 0 HRA O COBRA 0 ERI 5A l O FNB.n <br />(2) PAYMENT <br />r„c Adnrnwrsririi P o' mJ utvnis frryse,n:}' arc J�xe:mi,!eJ i,v a fie ahmhdz and invoked m die tmpinya 11w A.'.mi,tiscran ' n:. s doe ar rin:e of an- <br />aliarien. (Sm:rf, Uaknu nsiduw add-0iiaatry nx.)ddJirmul its may be andind.robedeamlintd byln>lrcdew ol':hz Plat .ltdi Jtinn. <br />swnoc I One To.,. So.. op ; ee I Adminu¢>dort F•x I other tcv I <br />i Retiree Billing <br />I <br />fA CD 3 /' <br />�(• y�l l�jJ') Grlrue_:.� !r tilC-..rk• I <br />• Fecs jm srbjwr to 8san±e pending revimv of Nan Deg:nncnc.utd informgnon. and deremintatron of reork (nvrhzd, Ux lilin;J <br />O Chick B.— 0 MaxerCmd O V;v, 0 Arneri:,,, ExFrrt <br />ufCardholde,;NJm•:cn Card; <br />— <br />C.trd a —. _. ._ —.. _..... Esp. D>r-. <br />(3) E-PAY <br />','ASCs sra:drai m<d,nd rut su.4:nisinn oFa(rains[rarun fcs ii via Ed'J:; l'/irU •I:i3 nriicr.'I:•l :C cunvndrufp ,'..doer, <br />mare.. Simph curl-0e:e the 4pinP wlte,v-i licilld.Mmvi.nd,bic>ad:r,,:arm:r :vurt or::,ide rile the At <br />oniv hr.... d •ing she or Jrmsmr in dm nunn..-apcciEed in dr. un !ruri_>riet:. the ltne:mee in d:e>nd:or:::[:on mprase» <br />:r<Y u• i re:.:!aciianioo ai Ct FAC ix:mnonu,: r>n:rion Poli ^•s1•[Igor AI'H \envoi'. P>rdciPn:[s. <br />nnac;:.d E rv,r—r Lim <br />�Gtrt <br />:1 u':' itasr.,n;:?m:i•rr l:h+ any nnovn: Xumlrer <br />'j rmn!.; nmrc;,l�v.. _. �irro no. ;:•.:..,:.d1.J:- Ta•gn: r•• •n, r .r::.r..uri,rr C7n .�.nu,wn'. .. <br />dnJ .amid nzm!� r: vc e::,r.en,,.r ::.ecJ::vrir.:i ;r; y.:::: y .u: •:..:a i•..:7:- <br />U <br />I'rr <br />vm:r eirez:,nt <br />[hz Nrntrinrion <br />cgwrzat.n[>eiai- <br />I <br />25E-77 <br />