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— (A) �~ le) a ,Icl--_ ----(off ___..... Vic) <br />- Coetrad aeenteontrad Pro. Tax Insuran¢ Cauleror Ise <br />i �...�._ (G) <br />11 <br />nelit 'Total a offevered <br />Year writtento Gmup eeneM Service Provider Name Self-Insu <br />ed ISl), jar; Part pants <br />(moldd/yr1(GloriniliAdualsl9 flR9 FVIlydn <br />ureJ l`) 1 ram a�adlM oepmdenu) <br />Heath <br />Dental ------- , <br />._De_ �_ __. .z .__•_ _. .__._ <br />Vision ' <br />Life <br />I___ <br />I <br />i <br />AD&0 <br />STD <br />LTD..._.._._._ <br />_....._ _. , <br />Voluntary/ Supplemental We or Aa&n <br />P/ellrtess _ _ <br />I <br />_Employee Assistance Program EAP)_- <br />• Stop Loss Insurance _._ _ . - <br />Vol <br />Othet ERISA Plans` <br />J <br />'Olney EalSAPlens:chzdkWthy:urroeipllnna ada6arto determ/na¢these plans are Emp/oyersprvisored?tans s59CT to EO: Exa <br />ples initude Prepaid legal <br />Serace; Srho/ars$p Ponds, 0ay{are (enteri yacdtion 8enejiK,ApyrznUceship aratherTmfning 8enefits,Noiiday/Sevuance Benefits, <br />and Np�sing Assistart¢Benefits. <br />GROUP HEALTH PLAN INFORMATION <br />Is Entity part of.' <br />a Controlled Group of Corporations under Code Section 41416); ❑ No <br />' <br />- a Group of ausiresses/Trades tinder common control ander Code Section 414(c) or ❑ Yes (see next question) <br />' <br />- an Affiliated Serile sGraupunder Code Sectton414(m) <br />'CI -iSeporo[ean <br />Acatfolnsarerequired. <br />If YES, are benefits/Premiums <br />/premiums paid from source? .O Yes 4 entiries n <br />aybelinder oneAppiicaffon. r <br />Under PPACA, current Group Health Pian is considered (sclect one): ❑ Grandfathered (GF) ❑ Nan- <br />randfatfiered (N_ GF) <br />Indicate if both items apply below: <br />1. you are considered an Applicable Large Employer (ALE) under the Employer Shared Responsibility provision of th <br />( Affordable Care Act (ACT), and; <br />2. You currently track employee hours to determine if any variable hour, Part-time, or seasonal employees' are "full <br />O Yes C] No <br />t <br />time" Employees for purpaias of health plan eliglblllty _ .. <br />Prescription Drug Plans Offered: O Creditable <br />_ <br />Non�Cmditable ❑ Roth <br />Medicare Part D Coverage: 0 No 0 Yes <br />r11llN ONLY: TASC ERISA • Special Instructions: <br />i <br />❑PCORICompliance Services (with TASC ERISA -free) PRICING'No Set -Up Fe <br />INFO: ' Annual Admii <br />O PCORI Compliance Services (with out TASC ERISA) _ . Based on nun <br />Fee (qua aw) <br />beroFemployees <br />(1)REQUESTFORINFORMATION <br />1 select all that apply to your current benefits and status: <br />j O (A) Health Reimbursement Account (HRA) <br />Cl (a) TASC HRA Client <br />0 (C) TASC Non -Excepted (Health) Flexible Spending'Accourt (NEFSA) Client <br />0 (0) Self -Insured Health Plan <br />0 1E)TASC H RA self -Administration Client /TASC Self -Administration NEFSA Client <br />if you checked ONLY boxes A and B and/or C, you tan skip Part 2 below. <br />:ail, Lo Employer InitialIip7aJ0 <br />ro-aats-ran:v Il VV <br />25E-65 <br />