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rj�tivl•gl` N'hRk r'r 19 3t,7Fr»rj+Yyn jf S 1S.,'.f G..« f.�tr3{ •. EsSu�"s'eS.S.Ic�.., n�i�ifi� �. 1isi7f�l"tay�aN'r�7pfatt iz�F.po.ta�'uruljuaoyFq�a,^a�ia'.. FULL I LIMITED I PLAN ONLY Number of Eligible Employees: Existing HSA in place? ❑ No ❑ Yes Existing Health FSA in place?ElNo ❑ Yes Ell Limited Health FSA - - -- - la IfYES, Indicate the Plan Type: . ❑ Limited Post -Deductible Health FSA ❑ General Purpose Health FSA +Limited Health FSA ❑ General Purpose Health FSA+ Limited Post -Deductible Health FSA Note: If you implement an HSA on a different Plan effective date than your existing Health FSA then you must amend your entire Health FSA to a Limited or Limited Post - Deductible Health FSA. Amend the Plan by downloading and completing the adoption of the TASC Plan Document as Instructed In your Welcome Kit. All participants are moved to the amended Health FSA. The IRS will not allow mid -year participant election changes. At your next open enrollment you can crier Health FSA, options. FULL I LIMITED # of EE Payroll Contributions: Payroll/Funding Cycle: ❑ Weekly ❑ Bi -Weekly _ _ C] Semi -Monthly ❑ Monthly ;_ El Other: -, _J—f_— 2" Contribution: �� payroll — - Participant Contribution Schedule; -- - - 1" Contrtbutionateso ie to Participant accounts used on above Last Contnbutlon mpioyer Contributions?: ❑ No ❑ Yes if YES, please complete all information below: Contribution Amount per Coverage Level: Single: $ Family: $ Frequency of Employer Contributions: 13 One Time: Contribution Date: ❑4V - — -- eekly ❑ Bif -Weekly ❑_Semi -Monthly El Monthly O _ Employer Contribution Schedule: I" Contribution: 24 Contribution: Far banking holidays, select one option:, ❑ Apply contributions next business day ❑ Apply contributions prior business day Pro -Rated for Mid -Year Enrollees?:❑ No ElYes If YES select a method below. ❑ As of Plan Start Date ❑ As of -Most -Recent Quarter ❑ Other: FULL I LIMITED I PLAN ONLY HSA Plan Start Date: / (mo/dd) HSA Plan End Date; PLAN FUNDING _ _ _ _ _ _ _ _ _ FULL To fund your HSA Plan, TASC will initiate ACH debits from the bank account and financial institution named below. Plan funding payments will be electronically deducted from the indicated bank account and automatic --- - ally submitted on your scheduled payroll contribution dates. ---_---- m --n your Bank Information: ❑ Use same ACH Info from Part of this. Application ❑ Use different ACH information as per, below: Financial Institution Name: Branch:; Bank Routing Number (9 digits): Checking Account N: ❑ 1 understand the pay dates can NOT be changed once the Plan is enrolled ❑ 1 understand TASC will send an email prior to withdrawing funds for my account and that I should contact TASC with any changes no later than three (3) days prior to the employee's payroll date. Disclaimer fora stand-alone HSA Plan (not combined with TASC FlexSystem): TASC has developed a service known as 'TASC HSA" that provides full administrative services for Health Savings Accounts. Itis understood that the client wishes to add the HSA to its current Sectlon 125 Plan and that the client acknowledges they have amended their Section 125 Plan to Include the required HSA language to allow HSA contrlbutlons to be pre -taxed and thele Section 125 Plan Documents and SPD's are current according to Federal Law. ADMIN ONLY: TASC HSA - Special instructions: Pages Employer Initial - T.LSSC TC -3923-010117