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Select a payment method for your fees due and complete the following Information for the selected payment method. Payment Method Aptlons' ` ACH (E Pay)' Credit Card' Involced _ Set-Up Fees: .n. ❑ N/A DUE NOW for all services Administration Renewal, • Not Available Admin Fees DUE NOW for. TASCHIPAA ACA, POP, Self-HRA ❑ I� and Additional Fees: ^ ALL FEES DUENOWforTASCERISA Information for Payment Methods ._ ___ �. - wFinandal institution Name:_sP Marean chaso&co. ..a_..e...e. _ m�State: (cA ___. _._- - -_._ __... . .. ACH (E-Pay) Information: Bank Routing # (9 digits) _ ;322271627 Checking Acct # 7661062375 Routing and account numbers are typically located at the bottom left turner of a blank check from your bank (varies). The roudn numberis always nine (9J di Rs long and enclosed bycolons. M LJ MasterCard ❑ Visa ❑ American Express ❑ Discover Card #. Exp. Date: Credit Card information: - _- -_- -- -- -� - - - - Name onnCard: ID Signature. ..,_,a__._..........�..„__....., Frequency: 0 Quarterly ❑ Annually (1-15 Employees defaults to Annually) ......._. ._n„._...�m�.>,.. B Same address from Section 1 ❑ Different address: Invoice Information: Bdling Contact Name: Mall to:Email: _.._ _. ......._ _ .. _.. _._.._ ... Street Address: ! City .State: zip: 'e -Pay Is TA. US stanaam metnoa ror suomisslon or aumrnistrationlees. With E -Pay, TASC conveniently deducts your fees from your checking account. Simply complete the box above, signing where Indicated. Please note ACH Information for each benefit's plan funding will need separate attention in their respective section of the application. All written debit authorizatlons must agree that the Payer may revoke the authorization only by first notifying the Originator In the manner specified in the authorizatlon. The language In the authorization represents the disclosure requirement associated with the clarification of OFAC economic sanction policies upon ACH Network Participants. 'Credit Card payment option is only available for fees submitted with this completed Plan Application. It is not avallable for future billing payments. This Group Plan Application Is a binding agreement between Total Administrative Services Corporation ("TASC') and you and, if applicable, the company or other legal entity you represent (collectively, "you"). By signing this Group Plan Applicatlon below, you accept the terms of the Service Level Agreement. You also accept the TASC HIPAA Privacyoffering as Indicated in Part 2 above for applicable service offerings and you acknowledge receipt of the attached HIFAA Business Associate Agreement signed by TASC that assures compliance for your records. Further, you, as Plan Sponsor and Plan Administrator, and on behalf of, the plan set forth in this Group Application, hereby appoint TASC and/or its subcontractors or agents to act as an authorized agent for purposes of receiving and/or retrieving electronic reports/responses ("Claim Feed Information") from the insurance carrier(s) listed in this Group Application or otherwise identified by you on your behalf. TASC and/or its subcontractors or agents use and disclosure of Claim Feed Information shall be subject to the terms of the Business Associate Agreement, IMPORTANT NOTE: The TASC ACA Employer Reporting term will continue for a 12 -month initial term, thereafter renewing automatically for one year terms. Early termination fees are described on page 15, under Termination and Renewal of Agreement. I have read, understand and agree to the terms and conditions stated in this Group Plan Application, the Service Level Agreement, and the Business Associate Agreement (if app cable) /,�,s�attested by the signature below, effective on the date of the signature. xDEmployer Signature: "0 X' Date: -z' (—rt Title: Executive Director of Personnel&I-vices Distributor/Agent Name: (Keenan &Associates MyTA Primary Account Rep Name: Yvette Fields ; Emall: INTERNAL USE ONLY: Assist MYTASC ID: 4709-1480-9358 1 Retail Code: Paget Employer InitialTASC TC -0823.010117 qll