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ap'k 'r„�-+Y.q`u�-, .r'� 7 O 1,' '� , �`• ..t yam' � a f ..•h M1 �'.,.iV ,.r..�ac.n -`_., ��r,%+� Select one TASC HSA Plan to apply for and complete the requested information for that Plan Type jos noted y Foriler tabs): ' j'• Set-Up Fee (duenaw) O,H$AFullAtlrnini5trailon �__- PRICJNGINFO ,Admin Fee-perpartidpanI 1 perdonth -TII ' • det•Up Fee (due pawl O HSA Limited Plan Administlation PR(CiNG1NFO aAdnilNFee-perparticipener ' iet•lJp Fee (due ndwJ � manth(No Minimum] ❑HSA Plan-Only Administration PRICING INFO No Admin Fee . PLAN INFORMATION uii juMltEo I PtnN ONLY Number of Eligible Employees Exlstmg HSA In place? ❑ No 0 Yes I _ ` Existing Health FSA In place? . 0 No 0 Yes 'Cl Limited Health FSA i fjYES, Indicate the Plan Type: 0 limited Post-Deductible Health FSA O General Purpose Health FSA +Limited Health FSA ❑ General Purpose Health FSA+ Limited Post-Dedu It tible ealtn FSA date than your existing Health FSA then youustamendyour endre Veal Note: Ifyou mplementan HSA and different Planerecdve -m FSA to Limited0.UmitedPost- Deductible Health FSA.Amend the Plan trydovmloac'ing and.completingthe adoption of the TASC Plan Document as Instructedlnyour eltom Xlt moved to lheamended Health FSA The IRS will not allow mid-year Participant election changes. Atyournext open enrollment you can derif alih FSA options. PLAN CONTRIBUTIONS. _�^ - I_�TFULL LIMITED" R of EE Payroll Contributions; Payroll/Funding_ Cyile: 0 Weekly 0 Bi Weekly 0 Semi-Monthly 0 Monthly .. a 9ther: ' - Dates appbedto Farddpant acdo'unfs based on dba6esdec edpoyrafi cYJz:_ Participant Contribution Schedule: 10 Contribution:;_ 2"a Contribution Jam— Last botri�ution: _f_/_` 1 Employer Contributions?: 0 No 0 Yes If YES please complete all Information below. Contribution Amount per Coverage Level: Single: $ Family: S _ ._ ._ ... Frequency of Employer Contributions: ❑One Time: . Contribution Date: 0 Weekly 0 81-Weekly 17 Semi-Monthly ❑ M nth(yi 0 Employer Contribution Schedule: VContribution:Contnhutio : _J. I For ban kingtlolidays,selectaneoption:❑AppfycontnhuticnsnextbuslnesYday ❑Apply con[ bubo spriorbus_ine_ssday �No❑Yes IfYESselectamethodbeloi4: f _ Pro-RatedforMid-YearEnrollees?: 0 As of Plan Start Date 0 As of.Most Recent Quarter Othi PLANSTART _ _ _ Fut. unuteo LPCAN aNLY_j Data:�- f_,4 mo/cid) HSA Plan End Date: _/_ .(rooldd)-ifopplkable� HSAP�E r .f1 PLAN FUNDING _ - i l FULL Tofund your HSAPlan, TASC will initiate ACH debits from the bank account and Bnoncial Institution named belosd. Pan fun int; payments will be eledronialfy deducted from the indicated bank account and automatically submiGed bn�your scheduledpayroll co tdbuti n dates. Bank Information Q Use. same ACH Info from Part'4 of thls Application_ C2 Use different ACH lnforme on asiper below: Rnanclaf Institution Name: Branch: Bank Routing Number (9 digits): Ch_ecking Accou tg: I - _ 0 1 understand the pay dates can NOT be changed once the Plan is enrolled. 0 I understand TASC will send an email prior to withdrawing funds for my account and that 1 should to act T> SC with any changes no later than three (3) days prior to the employee's payroll date, Disclaimer for a standalone HSA Plan (not combined with TASC FlexSystam):TASC has dereIoped a service known as "TASC SA",Illat• provides full administrativeservices lcnHeaith Savings Accountz Itis understood that the. client wishes to add the HSA to its current Secti 12S 11an and that the client acknowledges they have amended their section 125 Plan to include the required HSA language to allow HSA Contributions to a pre;trated and their Section 125 Plan Documents and SPD's are current according to Federal Law. I ADMIN ONLY:TASCHSA-Speciallnstructions: ,�—� ~^� y Page5 EmployerinIna _ gI� TASC Fd921-0lalt7 _(_U 'u 25E-60