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Select all benefits made available to the eggible employee(s).. These benefits are taken through salary_ deductions.
<br />0 Healthcare FSA- Medical Expense Reimbursement Account: $ 2600 Maximum Election (Employee & Family)
<br />Is employer-sponsored group health insurance offered to employees? ®Yes 0No»rfNO, you are not eligible tooffer this benefit.
<br />® Dependent Care FSA Reimbursement Account: Maximum $5,000; $2,500 if married filing separately (Employee & Family)
<br />8 Non -Employer Sponsored Premium Reimbursement (NESP): For qualified Individual Premium Plans not offered through any employer.
<br />Is employer-sponsored group health insurance offered to employees? ®Yes 0No»/fNo, you are not eligible tooffer this benefit.
<br />• Medical or Medical -Related Premium: Group Sponsored (Employee & Family)
<br />® Voluntary/Group Term Life Insurance Premium: Up to $50,000 in death benefits (Employee Only)
<br />® Disability Insurance Premium: Pre -taxing employee contributions will make benefit taxable compensation (Employee Only)
<br />0 Supplemental Insurance: Includes cancer, hospital confinement, Intensive care, accidental death and dismemberment (Employee & FamlIvI
<br />Medical/Office: JS�$-�C) ------- - -'- - -�5 Prescription Drug: -$-- $
<br />A_DMINISTRATIVE6PTIONSforTRANSIT/PARKING�ry
<br />_ _ m. f.............._,,.,_.�... x._...u....._,,.�_..,_._.._...v._.....
<br />If applicable, select options below for your TASC Transit and/or Parking Account. Defaults are based on the current IRS monthly maximum.
<br />Each optlon can be selected fo_r either or both benefits, EXCEPT_ the Terminal Restricted Card must ap ly to both accounts.
<br />_ Transit AccountW_� parking Account
<br />B Rollover ❑ LJ Restriction: Rollover Reimbursement Restriction IJ Terminal Restricted Card
<br />Days (190 default) _ _. Days (180 default) (applies to both Transit and Parking)
<br />Page Employer Initial ',�a(EiT Sc
<br />TC -3923-e10117
<br />Set -Up Fee (due now) T^
<br />® Flexible Spending Account (FSA) Full Administration
<br />PRICING INFO; I • Admin Fee -per participant, per month
<br />__ __ ______ _ ____ ___ __ __
<br />r
<br />_ -7 • Annual Renewal Fee
<br />❑ Premium Only Plan (POP) Administration
<br />^�J
<br />__`
<br />PRICING-INF6. • Admin Fee -per group, peryear (due now)
<br />❑ Transit Reimbursement Account (T/P)
<br />---------
<br />T • No additional fee w/flex5ystem Full FSA
<br />PRICING INFO
<br />--
<br />❑Parking Reimbursement Account (T/P)
<br />.� • Admin Fee -per participant, per month
<br />• Annual Renewal Fee
<br />PLAN.INFORMATION :_� FullFSA-
<br />POP TransitAccount Parking Account
<br />Number of Eligible Employees (each):
<br />❑ No W Yes
<br />Existing Plan in Place? - --
<br />❑ No Yes U No CI Yes W No 0 Yes
<br />- - - ----- --
<br />- -
<br />If YES, please complete the following: _
<br />ERISA 3 Digit Plan ft +
<br />-
<br />_ - I rv/A _._ f N/A
<br />H of Current Participants tss
<br />_
<br />135
<br />Name of Current Administrator conexls
<br />It -
<br />conexls
<br />PLANOPTIONS :.....�:. f.:t._._._.,.......,__V..,,...®...__,w..............._m,.......-_.,,..,....m..�._.,__..�_,FS_7/P„)
<br />....�.._.m
<br />Select options below and enter the information foryour Current Plan NEW Plan
<br />applicable_ current and new Plan(s): _
<br />- -
<br />0 Healthcare FSA Carryover (default $500) Carryover $:
<br />Carryover $: 500
<br />❑ Grace Period(default 2.5monti If Health Carryoverls GP End Date:
<br />GP End Date:
<br />^—J—l— _—f—f—
<br />also elected, Health FSA will be exdudedfrom Grace Period.
<br />iiRunoutPeriod (default 90 days after Plan End Dote) pO End Date
<br />I RO End Date
<br />Runout for afl trenefltsendon same date (_
<br />-_ _,—/—
<br />Select administrator for current FSA Plan Grace Period and Runout:
<br />❑ Prior Administrator U TASC'
<br />'IMPORTANT; Obtain the FlexSystem Takeover Checklist fer Information that be received belore Plan start date with TASC. Carryoverdata from a prior Administrator
<br />must be provided to TAscotter the pdorNon Year Runout has ended with the applicablefunding.
<br />AVAILABLE FSA PLAN TYPES-,.
<br />Select all benefits made available to the eggible employee(s).. These benefits are taken through salary_ deductions.
<br />0 Healthcare FSA- Medical Expense Reimbursement Account: $ 2600 Maximum Election (Employee & Family)
<br />Is employer-sponsored group health insurance offered to employees? ®Yes 0No»rfNO, you are not eligible tooffer this benefit.
<br />® Dependent Care FSA Reimbursement Account: Maximum $5,000; $2,500 if married filing separately (Employee & Family)
<br />8 Non -Employer Sponsored Premium Reimbursement (NESP): For qualified Individual Premium Plans not offered through any employer.
<br />Is employer-sponsored group health insurance offered to employees? ®Yes 0No»/fNo, you are not eligible tooffer this benefit.
<br />• Medical or Medical -Related Premium: Group Sponsored (Employee & Family)
<br />® Voluntary/Group Term Life Insurance Premium: Up to $50,000 in death benefits (Employee Only)
<br />® Disability Insurance Premium: Pre -taxing employee contributions will make benefit taxable compensation (Employee Only)
<br />0 Supplemental Insurance: Includes cancer, hospital confinement, Intensive care, accidental death and dismemberment (Employee & FamlIvI
<br />Medical/Office: JS�$-�C) ------- - -'- - -�5 Prescription Drug: -$-- $
<br />A_DMINISTRATIVE6PTIONSforTRANSIT/PARKING�ry
<br />_ _ m. f.............._,,.,_.�... x._...u....._,,.�_..,_._.._...v._.....
<br />If applicable, select options below for your TASC Transit and/or Parking Account. Defaults are based on the current IRS monthly maximum.
<br />Each optlon can be selected fo_r either or both benefits, EXCEPT_ the Terminal Restricted Card must ap ly to both accounts.
<br />_ Transit AccountW_� parking Account
<br />B Rollover ❑ LJ Restriction: Rollover Reimbursement Restriction IJ Terminal Restricted Card
<br />Days (190 default) _ _. Days (180 default) (applies to both Transit and Parking)
<br />Page Employer Initial ',�a(EiT Sc
<br />TC -3923-e10117
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