25E - AGMT - EMPL BENEFITS - Laserfiche WebLink

Home Browse Search

PLAN CONTRIBUTIONS 7 i rFSA� 7!P •.E Employer Contributions? @No❑Yes ,. Payroll/Funding Cycle (select ane.): El Weekly ❑ Bi -Weekly Sam! -Monthly ❑ Monthly � '❑'4thee t it Lontributlons In 12•mo Plan Year: i Dates applied to Participant accounts based an above salad all dpay}cycfe. Participant Contribution Schedule: VContribution: '� �)-y 2''° Contribution: ��j�%% Las Coa[tibution: )J�%% (hosed on Plan Funding schedule beloiv/fir the EstimatedDuteofAecciPtfEDn)) Other cycles: FSA ,POP T PARTICIPANT AND ELIGIBILITY R_EQUIf;EMENTS •_^ - select the employment requirement below that an eligible employee must m :at in grder to enroll in the Entry and Probationary Period: FlexSystem Plan at open enrollment, or atthe time of hire: ❑-On the date ofhire ❑ Vaofthe month after dateofhire E) 30 days after date of hire ❑ 1't of the month after 30 days of continuous employment i { ❑ 50 days after date of hire Cl 1" of the month after 60 days of continuous employment O 90 days afterdateofhire Cl Other kricludeo Excluded NIA 1 ❑❑ �, Members of bargaining units, Additional Requirements: p ❑ Part time employees re ular r/ scheduled to work (selxtal[thatappty)_— '❑' ❑ r❑ -i Seasonal employees regularly working at least t least hours per week wit hina year_ ❑ ❑ 141 Employees under years or age - -months - PLAN START_-_ '•-„�,. _ _ _- _,_ Flexsystam ddministrado tFSA __ Poe T/P, begin4 Select and complete one oft Oft, optiansto md:cate Fhe Plan Year and when ❑ Initial Plan Year(na prior Plan Fists)_ 0 Year Administration_ 2n° fid Sttc esslve Years w� ,41(mo/yr) Plan Start Date. First day of: (mo/yr) Firstdayof 9 Consecutive Months Conn_ ued: Tw ve (12) month perfad - Note:Plans need not ran an the calendarye_ar (i.e. mnuar 1. December3l) t O Renewal Date A_dministration (TASCadministmtion begins on Plan renewal date) Plan Start Date: day _First Consecutive a Months Continued: Tvielve (12) month period ____ , _ __•,•,j__ -,,,._,e,,,_,_,_„ -..._„f Mid -Year Plan Takeover Plan Start Date 1 Current TPA Plan at at zan (mo(ddI'/fI °0 Plao End Date 61 - 2d1r_ {mo/did/yrJ TASC FlexSystem Plan: as at 1 7 (mo/dd/yr) - _ _ - PLAN FUNDING �--�_,,,,,,._. i Fs�_ TIP This Scotian defines the Estimated f7dansFee (ECF)method utilized to make benefit payments to your FlexSystem Pan:ripants ECF 11c Mediated by determining the total contributionsforthe Pian Year(employe,andemployer) and divide that total by the number of payments scheduled un If the total ECF collected for the Plan Year r 'ECF iYpectedDate P)gecalpt tufts inti excess fees greater man +(ED11). this fee is adjusted as appliableformid-reorenrallment and election changes. paid claims for that Plan year, the excess will be returned to the Pian Sponsor is forfeiture under the Plan. Any fees ar Chargesde 'itlh this section are in I addition to the fees due underPart 2: TASC services and Fees. bank�information: To start this process: 1) choose Funding process, (a) vers your Expected Date of Receipt, and (3f enter you _ 53 TASC ACH (default): TASC initiates funding paymentvia ACH on the EDR. I �(1) ❑ Client MVTASCFunding. client initiates funding Payment via MVTASConorbefore the EDR.Note: Underthisatian,T{iSCwilluse•rourAccount s{ and Rcuting Numbers to post any unpaid funding amounts that arson(1)business y past, he EDR.Ako, additional f annual fee.will apply if ACH is not elected($10.Coper payrq!ll. (2) VeriP/ your Expected Date EOR is the payroll contribution schedule Indicated in the PlanCpntribudansectionto that TASC-will poll an Auto ACH from your designated account and apply the payrolls intribulions f each palyrdll cycle. Thlsls the date to year Pariclpant's I of Receipt (ED R); amount(s), This may or gigynct be the mune dote as the ?a rd cOcat's Payroll deduct? ndotea f(3) Sank Information: ❑ Use same ACH info from Part d of this Application ❑ Use different CH InformStateation as per below: i I Financial institution Name: : 1 f Bank Routing Plumber(9 digits): Checking Accou t0: _ ADMIN ONLY: FlexSystem •Special Instructions: T t "Toss Pagea Employer initis S( tGi927-0tJ' ❑ 25E-59