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I <br />.ase? Er!oleyer Initial •.tl��rTASC <br />Tc -M3 010117 <br />I <br />25E-62 <br />FULL SELF <br />�I�ect and complete one of the foilowin brroo tions Indicate the .Plan Year dates and when TASC HRAadmin_Istration <br />begin?. <br />Cl NEW HRA .Plan (no currenrplan exist^) i'�Year AJministration 2eda <br />d'Suc arrive Years <br />o: _ (mo/yr) <br />Plan Start Date: First day o_f: _j_y (Mo_/yr) First day <br />V Consecutive -Months. Continued: Tivel <br />a 112)month period <br />Plate. Plans not run on the calendar year Q.e. la <br />--Decemb&31). <br />_ _need <br />0 Mid -,Year Plan Takeover -select one setup option below(Yenrto-nate balances must be subminedwlth enrcgments <br />•u-cry/ <br />l alder YlIo� be entered)+ <br />OFUIIPIanYearsetup;or Flan Sponsor mustsubmitanaggregatebalance reportcfpoid(Pant <br />oimspaldyearto-date <br />to,pdJust the Padidppnt HPA balance <br />0 Short Plan Year setup: (fess than 12 months) Plan Sponsormbstsubmiton aggregate deductible credltrepo- <br />year-to-date to adjust the Paiddpunt HRA balance. Aifaws you <br />alpan/npantdalmspold <br />o e#e d o deductible credit td <br />your Participants based an the amount o/ the heplth_insinim" <br />ed"' lethathasbeen <br />satispedthusfac <br />�_ <br />—Enter plan Betas based on yowseletted setup: Plan Sart Date <br />�� <br />Plan End Date <br />Current TPA Plan:.- _/T/ .. (mo/rid/jry _j <br />= (mofdd/yr) <br />TASC HRA Plan: _/_j_ {mo/rid/yr) i _ <br />NIA <br />f PLAN FUNDING T <br />To fund your TASC HRA Plan TASC will Initiate AOl debitsfrotn the financial institution and bank accountnamed bet <br />r I <br />�anhlnformation ❑.Use•sameACHInfofromPart4o_f_thisApplication_ 0 VsediFemntpC'Hinformab)nasperheiovr. <br />Financial Institution Name <br />Bank Routing Number (9 digia).1 Checking Accoun <br />9: I <br />— <br />ADMIN ONLY! TA5C HRA - Spet)al Instructions: "- <br />Funding: _ % (Minimum of 25%) <br />x., � 4 .,, J .tL��YF•s*,ai �� 0 t a - 'b. is : .rxr' . <br />�.4 s -SEL.. <br />O COBRA Admtnistratfon & Compliance <br />• Se <br />NOTE: fie Premium Collection FOIm fsrequlred wtth completed uppficotfon;efare Plan titin be tetap. <br />•. __. . .. -. PRICING • Ad <br />Lip Fee (due nowt <br />I <br />In Fee -Per HE, Per month <br />Additional Serviee5 (addiefongl;Feesapply):. - ., .... INFO: • An <br />dal Rdnewal Fee <br />❑Takeover QuaRaed BeneHdarles (TCIe) COBRA Enrdiiees Ba <br />zd on inumberof employees <br />f5vtmi[7akeoverQuaflJtedDeneJJdor/Farm�foraachiTQB with mmpletedappticoticn)^✓- _ <br />! ^__ <br />PLAN INFORMATION <br />Number Employees an Healthlnsurance Plan: Total Number of Employees (pro-ratefar PT): <br />f <br />(Carreatcountneededforbillingpurposes) Current COBRA Administrator. 0Self 00 <br />er <br />- <br />_ ^. <br />or DIVISIONS �_�� _ _ <br />SUBSIDIARIES, AFFI-�T <br />__ I -._•T___ <br />_- <br />,UATES, <br />Identify all subsidiaries, affiliates, or divisions to Include under TASC COBRA and if they requlre a separate setup far <br />ervice�communica8ons: <br />Name: Separate. Name: <br />Saarat. <br />i) 0. 3) <br />i7 <br />2) JI <br />0 <br />PIAN START �•—� ___ _ <br />i <br />j Enter the month and year that the Plan Year•Mll start for theirst year c f TASC COBRA administration: <br />( <br />1 <br />f TASC COBRA PlonappFcation mus: be reeelvedby 15th ofmanth rim' <br />Fart day of: froplr) <br />to this startdete. <br />_�_ CDBRAP.ddepdum Sneadadifrequestedpinn startd to <br />Plan Start Date: <br />doe; no!nreetthls requirement. <br />f <br />1 OFirst of month, following qualifying event O Other(precse sped); below+: <br />, <br />COBRA PMod Begins: <br />C1 Day aFtzr.quali-tying evert. _ <br />I <br />_ <br />ADMIN ONLY: TASC COBRA - Special Instructions: <br />I <br />.ase? Er!oleyer Initial •.tl��rTASC <br />Tc -M3 010117 <br />I <br />25E-62 <br />