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Emial oyer Initia 'ITASC <br />TC-3923.Moll! <br />25E-57 <br />full <br />R M-0 <br />- <br />select a payment method for your fees due and complete the following Information for the selected payment mc:hod. <br />Payment Method Options: _iCH (E-Pay)l Credit Card' Invoiced <br />—M. I <br />Set -Up Fees: N/A I DUE NOw for all services <br />Admin F cas DUE NOVI for. TASC H <br />AA.FCA, <br />POP, Self -HRA <br />Administration, Renewal, <br />ERISA <br />and Additional Fees: ALL FEES DUE NOW for TASC <br />I <br />1"Information —for Payment e­th_0d5__ �_,_,_�__�__�.. <br />'CA <br />--.i •••---••---•• <br />Financial Institution Name: JP II -raw Clauaca, State: <br />ACH (B -Pay) Information: Bank Routing 0 (9 iff-03); =71n? Checking ACC it: . 65.195 2 a7s <br />&_ ng anduaccumf numbers are typrcaflytootad at the bottomieltoomarof a Munk chockfrom <br />"a urbankivaa.). <br />..The routing num_bera alway_t nine fsf diplts long and encfafe0byrof�ns.� _ <br />1 <br />El MasterCard Q Visa 0 American Express 0 Discover <br />Card R: Eq. Da.t.e:. <br />Credit Card Information: ,lame on Card: <br />W Signature: <br />Frequency: a Quarterly Cl Annually (1-15 Employees default; to Annually) <br />I <br />ZI same address from Section 1 0 Different address: <br />invoice Information:Pilling Contact Name. <br />' <br />Mail to: .Email: <br />� <br />Street Address: <br />City <br />zip: <br />rE.PayIYTASc,s standard method forsubmission I <br />t.s <br />C C no, Imply <br />eu, <br />complete the box above, signing where Indicated. Please note ACH information for each benefit's plan funding will need separate arte <br />fan 11. mspectivesection <br />I agree that the Paver my revoke the authorization only by first nourying the 0 <br />of the application. All wdreo debit authorizations mus. <br />the 62(ifiVitIO <br />111, <br />qina In the manner <br />Of C tnatflamissaPorIGO <br />specified In the authorization. The language In the authorization represents the disclosure requirement associated with <br />policies upon ACH NetMel PartICIPWItS. <br />'Credit Card payment option is only available for fees submitted with this completed Plan Applicadom Ifis not ariallableforfuture billi <br />I PsYnients. <br />This Group P <br />ble, the <br />company or <br />service <br />of the se <br />Level Agreement You also accept [he TASC HIPAA Privacy offering as indlcatedin PaK 2 above for applicable serrice oEfrings <br />HIPAA Business Associate Agreement signed by TASC that assures compliance for` <br />and you <br />our refords. <br />adInowledge receipt of the attached <br />Further, you, <br />SC and/or its <br />In Feed <br />subcontraCto <br />r its <br />Information") <br />subcontractors or agents use and disclosure of Clalm.Feed Information shall be subject to the terms of the Business Asz <br />d2te)lgreement. <br />IMPORTANTNOTE: TheTASC ACA Employer Reporting term will continue for a 12 -month initial term, thareafterren <br />ving btorratically for one <br />I <br />year terms, Early termination fees are described on page 15, under Termination and Ravaevraf of Agreement. <br />I have raid, understand and agree to the terms a ndcondifilons; stated in this Group Plan Application, the Service Lev, <br />I Agreement, and the <br />Business Associate Agreement (it ap�cabie) ttasted by the signature below, effective on the date of the signal L <br />a. <br />0 Employer Signature: Date: <br />Title: Executive Director of Personnel )§ervices <br />Jmy CP cs�l a 1-4709-1480- <br />Distributor/Agent ributor/AgettNanna: Keenan & Associates <br />358 Retail Co de: <br />Primary Account Rep Name: kYvette Fields Email: 'yrields@ke <br />nan.com <br />INTERNAL USE ONLY: <br />Assist IvlVTASC ID; <br />Emial oyer Initia 'ITASC <br />TC-3923.Moll! <br />25E-57 <br />