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9,,1R, Group ) Company Name: Clef of Santa Ana Business Federal IDk EJ TASC Suite K (1-8) ladaded 9&deg berme ilikf CA Business Planp licatlon _ .. _ _ _ , _. _ , NAILS/SIC Code Total If Employ es O TASC Form 5500 Preparation 972 Mature of Business: Cly Government Total k BeneFit Eliglh _ _. E a Em(�loyees zas lnrernor Use gnry: Otarge Olent quallller qJ •-.._ ❑ then 1 Health Insurance Carrier. CeiPER.S Medical Carrier Group IDk: 483399115e ene IDate: Na ! ,._.— Email .._ Fax _... _ :ti! 11 Please submit completed Applkationwit ❑ TASC HSA -Plan Only T,15C, rJo ew Bu IAass Department gone, required fees to: ne*buslnessetzsconline.com (E08)'661.5638 23021ntern Clonal P.O. Box 11140 LontaetName: Ca'doHanes Email (m Uanes�sana-a Title: een�RtsB Ca mPensa9an9upeMsar Telephone .(713)847-6967 dg ) Company Name: Clef of Santa Ana Business Federal IDk EJ TASC Suite K (1-8) ladaded 9&deg berme Physical Address: (no PO sex) 20 Chic Center Plaza 1134 City: Ana. State CA Zip 92702._ _Sa_n_ta Maitin Address:fnarroBOX J Lib/: State Z ip: _ .. _ _ _ , _. _ , NAILS/SIC Code Total If Employ es O TASC Form 5500 Preparation 972 Mature of Business: Cly Government Total k BeneFit Eliglh _ _. E a Em(�loyees zas Tax Filing Status ❑ C -Corp ❑ S -Corp ❑ Partnership ❑ Sole Proprietor ❑ Non Profit ❑ LLC ❑ then 1 Health Insurance Carrier. CeiPER.S Medical Carrier Group IDk: 483399115e ene IDate: Na ! CamierAM/Rep Name: ;wane Flelda AM/Rea Email: , y9elds(dkeenan.s I Are you a current TASC Client? Rtlo ❑_ Les_t If yes, please provide yaur_L_2-Digit_TASC IDk. Name existtng/active TASC services: Select the new TASCservice offerings) for this application (and complete each corresponding section under PAT 63: I �` Check the hwerjorearh A TASCSuite Add -On Offerings(apdonaj:Complee app, :ection for :electi ons EJ TASC Suite K (1-8) ladaded 9&deg berme O TASC ACA Employer Reporting ❑ 7AffRA _ ❑ FASC FMLA ❑ Eligibility Deterrldnad _ a complete cans scathe❑TASC Non-Diserlmihation Testing 0TASA Transit Account SECTIONA Morin this appamtion. O TASC Form 5500 Preparation l Cd Parking Account BENEATACCOUNT MANAGEMENTSERVICES BENEFIT CgNTINUATION SE vICESj SECTION D H El FlexSystem FSA` ❑ TASC COBRA ❑ 46 rakecver_ U FlexSystem POP _ ❑ FASC FMLA ❑ Eligibility Deterrldnad I SECTION E Transit Account SECTIONA --. ; .___..:.. 't_ .,..:__...._ ..--......... _, i;0ii1PLIANeEs6`RVit'_._.. . _ Cd Parking Account ❑ TASC ACA Employer Reporting f2-Prc atrac J SECTION F O TASC HSA -Full ❑ TASC ERISA I ❑TASC HSA -Limited SECTION ❑ Medicare Part DNodcas ❑ TASC HSA -Plan Only O Late 5500 Filing ❑ PPACANotices iSECfIONG ❑ TASC HRA -Full Cl Carrier Certificate Ci Add Wrap Doc(s) ❑ TASC HRA Debit Card SECTION![ ❑ TASC PCORI(with TASC ERISA -free) • TASC HRA -Self C) TASC PCORI (without TASC ERISA) j SECTICNH ❑__TASC G)veBack SECTION 1 O TASC Form 5500 Preparation l SECTION 1 C] PayPath° 'camprams araea m ❑ TASC Non.-Cliscrinfination Testing SECTION) ❑ TASC Funded HRA' Pion epP71-odan- i ❑ TASC HIPAA SECTION x Enter each Service Offering selected In PART Z and the applicable fees in the pricing chart below: New Service Offerings: — One Time ,. Administration Min WDM go-_. ,.___ . _ FlexSystem FSA t3C9 .$14,25 .$;100 FEES: Page 3 *3913-010117 Fees �. S;a.25 I Employer Initial �IVASC 25E-56