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Contact Name: 1 Email: 'D FI i ' ,J Per Payroll File i 4... 'R`„�'S.'h] T �1-'_.rSI.C. W.il. .. .mYj•F+_L.'��'��t�' °�i4L�J.1rFAli . ...�.T'..,i%3}'�'*['.R YY ALE Status Information ]�--- -- _-,�---_--- -. -_-- - -.-- ..----.---_. ❑ ALE with Insured (Medical Plan ! Applicable Large Employer (ALE) Status: Q ALE with Self-lnsured Medical Plan • Set -Up Fe. &Compliance /doe -�own �Z�iy.�y.'.L. / u ❑ FMLA Administration , Admin Fe ;PRICING - peF• mplayee, per month live Minim Additional Servmes(ad�tlbnvlfees apply). _ - INFO: m) ❑ FMLA Eligibility& Entitlement Determination gree of charge within a WCsviteJ • Annual Re LSelect one: ❑ Submit eligibility (Ile permanth ❑ Submit eigibflity file per event _ ewal ee -. -••-I•--^.•^^------•-• ❑QualifyingOFFer Nle!hod ❑ S3';'S O McCrod ' PLAN INFORMATION i _ __ ---- .. ----.- •� Number of Company Locations: .or Page Employer initial Number of Employees: tc.sa;l mau: Number of EES currently on FMLA Leave: Enter Location Name(s): { .(oddiNonolfeed apply per takeover a[ implamantation) _ Current FMLA Administrator(enrerbevaw): ) Enter anystates doing commerce: ❑FMSeiP O TPA: I Reporting per Location?: ❑ N ❑ Yes'(nextgaesaon) _ LA to run concurrent with Porkers O, yes if YES/enter locations and contacts: I Compensation and Short-term Disability Plans: Cl No O Manual Report(viaonifnefarm) i Method of Reporting FMLA Hours: 0Data Feed (via recurring6(efrom yoGr timekeeping syste forFMA time use d) } ollmg BackwCalendarYear ❑ Aard ffINIA12-monthTracking Type(se%pt ore): QgolhngForward t]Plan year vv/StartDate of J_ daysprlarto this St tdota TASC FMLA'Plan Start Date: - _J=(mo/dd) 'P'anapplicadon miurbe mceived 10 �_- ADMIN ONLY: TMC FMLA -Special Instructions: j I - 1. .t�� �`---_•t PRICING ' Set -Up Fee (duen w) ❑ ACA Employer Reporting (2 -year cantract required)• Annual Admin Fee •INFD fdue:r(ow) (employees , Based on number REQUIRED: Please select your Employertype and the appropriate service offering selection for your ACA Re_por Ing needs: Ent vel �. Le vel ofService Needed .. Hou, Tracking) ❑ Single ALE or Government Entity (one EIN): ❑ Comprehensive Plan (includes Voriab _ ❑ Reporting Qnly Hour j Tracking) ❑ Aggregated ALE (more than one ON): Q Comprehensive Plan /includes Varlabi Controlled Group or Government Entity ❑ Reporting Only ❑ Non ALE (under 50 FT employees): Employee Mandate Only _ IT Employer Inforinatioh`^ Contact Name: 1 Email: 'D FI i ' ,J Per Payroll File Tele hone: !File Frequency: iMonthiy ALE Status Information ]�--- -- _-,�---_--- -. -_-- - -.-- ..----.---_. ❑ ALE with Insured (Medical Plan ! Applicable Large Employer (ALE) Status: Q ALE with Self-lnsured Medical Plan ❑ Non -ALE with Self -Insured Medical Plan (10948 and 10958 Filing » nol furtherihfo needed. -- - -- -- —.. ,.-_. .�-__._._.... If you are a `NON AL"" with Self•Ins -gd M=d' I Plan. you DO NOT need to arovide the information belrw- Plan Information and Services Please indlcaf whether you will be Including in, op ionai services baler (response requlrad for pricing): _ I i Variable Hour Tracking: ❑ Ye_s ❑ no Minimum Essential Coverage offer indicator: ❑ -1Fs ❑ No ! The rASCAC9 Emplayer ReportingAdminis:radon Manual will help You answer any of the following items that:vod ❑QualifyingOFFer Nle!hod ❑ S3';'S O McCrod ' i have not aiready determined. Select only those that apply (lesr_plank if unsure): _ ._.-_......�_..—.-...- ....__...... _..._.._ .or Page Employer initial 0L �'gTASC tc.sa;l mau: 25E-63