Laserfiche WebLink
-'» <br />(2) PLAN PARTICIPANT COUNT- <br />I <br />En_terthe following Participant counts (see instructions below on how to court Participants): <br />f + <br />1st day of the 1st month ofyour Plan Year• <br />Participant . ls[dayofthe 4thmonth,ofyouePlan Year: <br />count as pf: 1st day of the 7th month of your Plan Year <br />1st day of the 10th month of your PlanYear: <br />INSTRUCTIONS for Participant Count (based on answers InPart1 above): <br />1 <br />-BoxA ONLY.participant Counts should equal the total number of HRAor NEFSA Plan Participants' ant <br />le firsday of each quarter <br />Box A and E ONLY, or during the Plan Year. <br />Boz C and E ONLY ,. ... <br />Participant counts should equal the total. number ofsalf-insured llezlth Plan Pa Ucipants <br />.. <br />on thy first day oFeach <br />BOTH Box A and D, or quarter during the Plan Year. <br />` BOTH Box Cand D Ccunteach Health. Plan Participant with self -only coverage and thenadd to that the nuri <br />1 <br />er of Participants withother <br />thanselfanlycoveragemuldplied by235(the same Plan yearlsonimed%or both yovrHLia <br />self -f ured Healthp!an), <br />Participantcounts should equal thetotainum bee of selflnsurad Health Plan Partcipants <br />antb, Rrstday of each <br />quarterduring the Plan Year: <br />Box DONCY Codnteach Health Plan Parttdpzntviith self;only coverage and thenadd to that the num <br />or of Ifarticipants with other <br />than self only coverage mulUplfed by 2:35 <br />{ . <br />-1 . nclude all Coo RA Participants in yourcount but do not lndude'onyspouses brdependents that may, be coveredfundE <br />r the Flan. <br />ADMIN ONLY: TASC PCORI - Special Instructions: <br />S ^t � T J��V'.�r �� O- C a 'LII, • ��£�� - <br />(dug flow) <br />fbenegts(odditicna_/feeg+) <br />1 PRICING Annual Admfn Fee <br />O IRS Form 5500, Preparation INppf Based_ onnumb_nr <br />+Late Fliing far Form SS007 ❑ No ❑ Yes if YES,. enter number rf late Rlings: <br />,VOTE-. Thi7efferlvis onyferangaing 5500 Plon&notformztnmers who are getting 5500prepjR anothereffeling. lfgE�1jlate/1 <br />a0sn eded, p/eosezefect urNer <br />�—� <br />I WC ERISA offering <br />ADMIN ONLY: TASC Form 5500 Prep - Special Instructions: <br />j <br />f <br />+ <br />` • �a. I .. �.: .. '�' <br />1 - ; r• -,; � <br />w) <br />(due7{ow) <br />PRICING Set -Up Fee (ding <br />P <br />❑Ma Testing RICIN • Annual Admin Fe <br />n -Discrimination <br />Basedonnumbe <br />of employees <br />___ __.____• <br />j PLANS TO BE TESTED_..-...--.._..,_. <br />{ Select Opal appfy,and indicate the start/enddatep for Plan Yearto betested: <br />art Date: EndDate: <br />❑ Premium Only Plan (POP) /Sectlon 125 Plan): Eligibility Test, Contributions & Benefits Test - <br />Availability & WIT zation,.Key Employee Concefltratfon Test <br />i <br />❑ Flexible Spending Account (FSA) - D"ependeet Care (Section 129 Plan). Eligibility Test, <br />�— <br />Contributions&Bengt,Test, More than 5% 00ners Concentration Test 5595 Average eenefits Test <br />�OFlexible Spending Account (FSA) -Medical: Eligibility Test, Benefits Test <br />O Health Reimbursement Arrangement (HRA): Eligibility Test, Benefits -rest <br />O Self -Insured Medical Pians: Eligibility Test, Benefits Test <br />Group Term life Insurance: Eligibility Test, Benefits Test <br />Plate: Group employees of 0Y entities must be tested if entity is a member ofo contralled group ofcorporations tra as, <br />or bcsinesses under ` <br />common control or an of dialed service. <br />ADM IM ONLY: TASC Non-Discnm Testing -Special Instructions: <br />age 11 <br />Employer initial <br />N'--, <br />NIIY", <br />raast:as 1" <br />25E-66 <br />