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0—ntrolleu Group: Please Indicate if you are a member of any of the followhrg: (required) <br />• a Controlled Group of business entities under JR5 Section 414(b) 6r (c); ' <br />P Q 4 ❑ Vas »it ye:,[er <br />low' <br />• an affiliated service group under IRS Section 414(m); Sir <br />an arrangement described under IRS Seddon 414(0), , <br />Government Entity Are /ou are a Government Entity that has reportable employees under l <br />more than one EIN number"? <br />Otto O Yes» If Yes,ldw' <br />•If you answered YES to either question above, please complete the information in the section below far each meinmity within the <br />Aggregated ALE, placing the entity with the most employees on top descending down to the entity with the fewest ees. A Plan <br />Appilcation will need to be submitted separately for each entity. <br />Entity's Legal Name Entity's EIN.Number. <br />If there ere morethan 15 amides to report, please provide the remainder on an additional document. I ) <br />ONLY: TASCACA- Special Instructions: <br />❑ ERISA Compliance Services • Set-up Fee (d <br />PRICING + Annual Admin <br />NOTEolpa wln10?1.n Mefrs[q(the month lit, nhth opplfcadon is retaived. <br />(NFO: Based on num <br />AdditfonalServices (addrtlar_ioleesapp!/J: _. <br />Cl Medicare Part D Notices ❑ PPACA Notices` O Form 55OG Late Filing (x of <br />a no."."J( <br />ee(,Vb Minimum due now <br />)( ) <br />er of,lmployees <br />_F_ <br />ears be filed!__) <br />O Additlonal BeneftPlans(9+) Cl Professional Services (billed hourly) O Wrap Documents• Ind. vldu I/Sepslate <br />Affiliated Employer <br />0 Carrier CertiFlcates of Coverage attached to Plan Document/SPD <br />ri,, key avtamednLy renew uanuopy <br />$nAyselecti addition! Wrap Documents are needed beyond Included Mega -wrap Decumenr <br />J The following benefits are subject,to ERISA requirements. Please complete each column as R relates to all benefits. "eretl by the Employer. <br />IMPORTAN-f Not Your Plan Document/Summary Plan Description (SPD) will be prepared based on youranswers each question so please be <br />t sure to answer these questions accurately and in agreement with the insurance certificates or summaries for these aneR#s.7hose Insurance <br />jcerVicates and suimmaries will be Incorporated by reference in your Plan Document/5PD and to effect comprise an mporTnt part oiyour Plan <br />j Document/SPD. Refer to KEVbelpwfor each column; <br />I Column A: Applicable health & welfare benefits subject to ERISA- Indicate by completing all columns B -G fort neflt.9loHered by Employer. <br />t For each applicable benefit offered, enter the Month and Date for the ACTUAL Contract Year of thePciirywith each abler. <br />Column B: Ex.raple.- Health— Contract Yearis:anuary 1, renews every January 1 I <br />Column C: 's fine Contract for this benefit issued ht the group name or Individual? Enter "G" for Group, or'9' to;]{individual. <br />i Column D: For applicabla banerlts offered. are employees allowed to pre -baa Their contributions under your Set an li5 Plan? <br />Enter "Y° for yes. or'N"for no. <br />eve Employerinitht G� 9IVASi <br />TC -3323-010117 . I <br />25E-64 <br />