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I�4 S <br />N <br />Please submit completed Application with <br />required fees to: <br />0791M�' <br />Email -f <br />X Mail <br />_TASC, We New Business Department <br />newbuslness@tasconline.com (608) 661-9638 <br />2302 International Lane, P.0, Box 14140 <br />Contact Name: Cattle Hanes <br />Email <br />Title: <br />Telep <br />Company Name: City of Santa Ana <br />Busing <br />Physical Address: (nop000x) 20 Civic Center Plaza, M-34 <br />CILY: <br />Mailing Address: (no Po Box) <br />City: <br />NAICS/SIC Code: <br />[3 TASC Suite # <br />Nature of Business: city Government <br />Cl TASC ACA Employer Reporting El TASC HRA <br />Tax Filing Stat= U C -Corp Q S -Corp El PartnershlD <br />Q Sale Prc <br />tjneaten insurance Larrier: : Qa1PLRS Medical <br />Carrier AM/Rep Name: irl Yveft Fields <br />ne: 1(714) 647-6967 <br />Federal ID#: <br />Santa Ana State: ICAZip: �92702 <br />State: f Zip- i <br />Total 4 Employees; i)72- <br />­­­ - --------- <br />Total 9 Benefit Eligible Employees: 245 <br />'fetor U iNlor_-_Pro1ltC_1LLC - _01l <br />IDU: � 4843991156 RenewaTDate: Na <br />p Email; yfields@keeman.com <br />Are <br />! 12 No <br />If Yes, please provide your 12-DigitTASC ll)h <br />Min <br />you a current TASC Client? _U_Yes_l <br />Name existing/ac ASqse services es: I <br />Annual <br />Select the new TASC service offering(s) for this application (and complete each corresponding section under PART 6 <br />FlexSystam FSA <br />Set Up res <br />$ 300 <br />check the boxesfor each <br />TASC Suite Add -On Offerings loptional): complete app section for sale tI..;­.-j <br />[3 TASC Suite # <br />Included offering below <br />Cl TASC ACA Employer Reporting El TASC HRA <br />A complete each section <br />EJ TASC Non -Discrimination Testing 0 TASC HSA <br />within this application. <br />U TASC Form 5SQ0 Preparation <br />ENEFITACCOUNT MANAGEMENT SERVICES <br />BENEFIT CONTINUATION SE RVICES <br />F4 <br />2 FlexSystem FSA <br />C3 TASC COBRA Q QB Takeover <br />17$ <br />11 FlexSystem POP <br />C1 TASC FMILA D Eligibility Determination <br />SECTION E <br />0 Transit Account <br />SECTION A <br />....... <br />�4.25 <br />$ 100 <br />$ <br />COMPLIANCE SERVICES <br />W Parking Account <br />0 TASC ACA Employer Reporting (2 -yr contract) <br />SECTION F <br />0 TASC HSA -Full <br />El TASC ERISA <br />Q TASC HSA -Limited <br />SECTION B <br />El Medicare Part D Noticesi <br />j <br />Q TASC HSA Plan only <br />El Late 5500 Filing 13 PPACA Notices <br />SECTION 6 j <br />0 TASC HRA -Full <br />Q Carrier Certificate ClAdd WrapDoc (s) <br />0 TASC HRA Debit Card <br />SECTION C <br />Q TASC PCORI (with TASC ERISA -free) <br />Q TASC HRA -Self <br />Q TASC PCORI (without TASC ERISA) <br />SECTION H <br />0 TASC GiveBack <br />SECTION I. <br />Form 5500 Preparation <br />SECTION I <br />--------------------❑TASC <br />TASC Non -Discrimination Testing <br />SECTION J <br />TASC Funded ll <br />plan application <br />El TASC HIPAA <br />SECTION <br />K <br />Enter each Service Offering selected In PART 2 and the applicable fees In the pricing chart below: <br />New Service Offerings: <br />One Time -7 <br />--m­n's—t'r—�t —on <br />'Ad <br />Min <br />Annual <br />Additional Services aq <br />FlexSystam FSA <br />Set Up res <br />$ 300 <br />I Fees <br />$ 4.25 <br />Admin Fee <br />oqo_L <br />$ <br />I <br />Re nawal Fees <br />1 <br />and Fees <br />-$ <br />F4 <br />TOTAL FEES <br />17$ <br />� <br />300 <br />�4.25 <br />$ 100 <br />$ <br />too <br />Page I Employer Initial ,6TASC <br />TC -3923-010117 <br />