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PLAN START euu se�F Select and complete one of the following two options Indicate the Plan Year dates and when TASC HRA ad minlstration begins. ❑ New HRA Plan (no current plan exists) 1`r Year Administration 21a and Successive Years Plan Start Date 1 First day of: J (mo/yr) First day of _ it Consecutive Months Continued i _ Twelve (12) month period Note: Plans need notrun on the calendar year (Le. January 1 -December 31J .._...._-...._.__.._..., _....._d..._ __.,_._._ -__._...._..___._....____.r.___.__..,. -...__.._..-_.__...,._W_-_....___..-.-._.._..___ Mid -Year Plan Takeover -select one setup option below (Year -to -Date balances must besubmitted with enrollments In order to beentered): ❑ Full Plan Year setup; or Plan Sponsor must submit an aggregate balance report of participant claims paid year-to-date to adjust the Participant HRA balance ❑ Short Plan Year setup; (less than 12 months) Plan Sponsor mustsubmlt an aggregate deductible creditreport ofparticipant claimspold year-to-date to adjust the Participant HRA balance. Allows you to extend a deductible credltto your Participants based on the amount of the health Insurance deductible that has been ^MrnN-J (mo/ddlvr) —-/ Current TASC HRA Plan: v Enterplan dates based an our selected setup: Plan Start Date _Plan End /A To fund your TASC HRA Plan, TASC will initiate ACH debits from the financial institution and bank account named below. _._.._-_ ...__.—... .--..- --- ---- __--. - ---- - ---........ -----'- _ _. 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): Checkine Account It: ADMIN ONLY: TASC HRA - Special Instructions: 'rY �q raj .11Nfil rlq MA A9, 8'522 M by Jnr *;ri'ay{t� Eh "liTdr iy n i� d a& R �',;1 r 'vy�birifir%'r Jl .(` "' Rk �gy� S, ''.PeFs',��'bf 3-r-'d'Iq.p,r r ti+Av"iGePs, L1 Y h rTt '%ktiktxa ..9Va �. �,Illl,+Jbkri .4+rai`1L�r'...,r.`LSP'16e'lP%�'I:.a�?�'i.-5fsu3�la�a w^'�.w'.15�eI�:nod Naii ❑ COBRA Administration & Compliance Additional Premium Collection Farm Is required with completed application before Pion can 6e setup. ; • Set -Up Fee (due now) NOTE: The - _,. PRICING . •Admin Fee -per HE, per month pal Service9_(additionaffeesapply); INFO: •Annual Renewal Fee ❑ Takeover Qualified Beneficiaries (TQB) COBRA Enrollees • Based on number of employees (Submit Takeover Qualified 9eneflclaryform(s)foreach TOO with completed amlimNon) _ PLAN IIMURMA HUN , Number Employees on Health Insurance Plan: ! _' Total Number of Employees (pro_-r_ate_forPT): (Current countneededforbillingpurposes) Current C_OB_RAA_dministrator. j OSelf ❑Other: SUBSIDIARIES, AFFILIATES or DIVISIONS-. Identify all subsidiaries affiliates, or divisions to Include under TASCCOBRA and if they require a separate setup forservice communications Name: --- -- -Separate Name: Separate lj O 3) ❑ _ 2) ❑ 4) .. _. ❑ PLAN ART _ .�;_..._...-.,...... -- - - - .....,.�...m�_- Enter the month and yearthat the Plan Year. will start for the fast year of TASC C08RA administration: TASC COBRA Plan Application must be received by 15th of month prior to this start date. _�_ (mo/yr) Plan Start Date: 'First day of: COBRAAddendum is needed ifrequested plan start date does notmeet this requirement. COBRA Period Begins: O First of month, following qualifying event - ❑ Other (please specify below) O Day after qualifying event _ ADMIN ONLY: TASC COBRA - Special Instructions: Page Employerinitlal iTASC TC -3933-010117 L—