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To conclude this application, please complete each Section below for the service offerings selected in PART <br />For a TASC Suite, complete each section for the service offerings Included in the Suite. <br />Select the FlexSystem Plans) you are applying For and enter the requested informadonwhere Indicated for e4ch Selected Plan: <br />_— • Set -Up Fee fd <br />4 nowi <br />UFlexible $pendingAccount(FSA)Full Administration PRIC)NGINFOI • AdminFee-Pr <br />participant, per month <br />11 <br />. Annual Rene <br />Fee ( <br />Ell Premium Only Plan (POP)Administration .PRICINGIINFO: •AdminFee-praroup, <br />peryearilduenow) <br />I T^- Naodditional <br />C3Transit f2elmtiurseinent Account (T/P) . <br />eew•I/pfexSystem <br />Fu11F5A <br />I. <br />---- PRICING INFO: •AdminFee —p <br />rpartldpanp <br />per month <br />❑ParldngReimbursement Account (T/P) . Annual ew Ren <br />IFee <br />PLAN INFORMATION_ — Full FSAL POP Transit Accou <br />t <br />Parking Account <br />Number of Eligible -Employees (each): <br />i <br />❑ No fl Yes ❑ Na ® Yes 3 No Cl Ye <br />( <br />I H No U Yes <br />Existing Plan In Place? ' i - . <br />If YES, please complete the fo)lowing: <br />. <br />1 -ERISA 3 Digit Plan g:_ I NJA <br />:NIA <br />f R of Current Participants: 135' 135 <br />Name rre <br />IL Nae of CuntAdministrator: canals [[ Conaxrs <br />— <br />PLAN OPTIONS_,_ <br />F -S& TJo <br />o <br />--Select options below and enter the information for your Current Plan — <br />N <br />Plan <br />[.applicable current and new Plan(s):.. <br />fj H Healthcare FSA Carryover (defauitssco) Carryover S: Carryo <br />_•^•.- <br />._ <br />er5:1 <br />�--,-- <br />500 <br />❑ Grace Period fdefoult2.5manrhs): 1i8ealthcuoyover6 I ^---r <br />-. GP End Date: GP End <br />Date: <br />_ <br />_j_j_ <br />.. 0 eler:dd, Health wRl be euludedJmm Gmml'eripd. (_ _ _f_/_ <br />a15 <br />El Runout Period fdefauft3a dayrafterPlan End pate)—f-1-- <br />RO End Date. , RO End - <br />ate: <br />—1_�— <br />eunbutforollbenefluendons6me date <br />Select administrator for Curren FSA Plan Grace Period and Runout: ❑ Prior Administrator 3 T <br />Cs <br />4NIPORTANty0brelo theflosystem TakeoverCheu'iAJorlryormotlan rhvtmvsrberecelvedW.Pone Plonsraridare with TASC ongave alujifamrprlarAdminaaurar <br />must be provided m TASCe@ee the pdorPlon Year Runouthds ended yAth the opplmblefa dtng. II <br />3 Healthcare FSA -Medical Expense Reimbursement Account! $!Eon Maximum Election (Emploee & Fanily) <br />is employer-sponsored group health Insurance offered to employees?R)Yes ONo>>TN0,youarenctef "bletoito�Rerthlsbenera. <br />03 Dependent Care FSA Reimbursement Account: Maximum, $5,000; $2,50 olfmariiedfilingseparately(Empi ee&�amily) <br />B Ndn-Employer Sponsored Premium Reimbursement (NESP): For qualified Individual Premium Plans not "eyed through any employer. <br />Is employer-sponsored.group health insurance offered to employees? ® Yes O No » /JNa, youarenot at Me toloffer this benefit. <br />3 Medical or Medical -Related Premium: Group Sponsored (Employee & Family) <br />8 Voluntary/Group Term Life Insurance Premium: Up to S50,0001n death benefits (Employee Only) <br />Id Disability Insurance Premium; Pre -taxing employee contributions. -Will make benefit taxable compensation (E ployer Only) <br />KI Supplemental Insurance: Includes cancer, hospital confinement. Intemive care. accidental death and dismerrerment (Emplovee & Family) <br />8 Medical/Office: $ 5ti $ r"' V Prescription Drug: <br />Defaults are bated on the current <br />Transit Account f Parking Account <br />i'-------------- -- -----I I Terntinal Restricted Card <br />3 Rollover 7 Reimbursement Restriction: ; 3 Rollover ❑ Reimbursement Restriction ( pages (o burl Tmnsir undPnMny) <br />_ Days hRrda'aulr) Days hap delaury q i j <br />— --'— <br />Pace Employer Initial Gi/2" QgIjVASC <br />ic-3923.410tt] <br />i <br />25E-58 <br />