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Aggregated ALE:Information Controlled Group: Please indicate If you are a member of any of the following: (requlred) ------- ----- ..._-----..-------- • a Controlled Group of business entities under IRS Section 414(b) or (c); ❑ No ❑ Yes » If Yes, see below* • an affiliated service group under IRS Section 414(m); or - • an arrangement described under IRS Section 414(0) Government Entity: Are you area Government Entity that has reportable employees under ❑ No ❑ Yes » if Yes, see below* more than one EIN number? "if you answered YES to either question above, please complete the Information In the section below for each member entity within t h a Aggregated ALE,placing the entity with the most employees on top descending down to the entity with the fewest employees, A Plan Application will need to be submitted separately for each entity. _ Entity's Legal Name Entity's EIN Number I I `there are more than 15 entities to report, please provide the remainder on an additional document. T ADMIN ONLY: TASC ACA - Special Instructions: ��t°t�a.�5•�„.ria_a.,^��..,�.n.:..�.�,.,,,s-rc:€ld'.,.d_-�x�.c-...a'v�4,�s,.v.>3,�5'd��?At�"k��.c.-.fi�3s�" iw:.��e,W� �'.,.k� �'F� tt}�.��7u,�S�rM�� iihBi'aniia� ❑ ERISA Compliance Services PRICING ' Set-up Fee (due now) NOTE: Plan cvdl begrn on the fast of the month In which application Is received. •Annual Admin Fee (Na Minimum) (due now) _. .. _ .._ ....._ __. . INFO: ; Additional Services (additional fees apply): Based on number of employees ❑WMedlcare Part D Notice' ❑ PPACA Notices' ❑ Form 5500 Late Filing (ft of years to be filed: ❑ Additional Benefit Plans (9+) ❑ Professional Services (billed hourly) ❑ Wrap Document'- Individual/Separate Affiliated Employer ❑ Carrier Certificates of Coverage attached to Plan Document/SPD 'Services automatically renew annually p 'only select if additional Wrap Documents are needed beyond Included Mega -Wrap Document I nCRICCITC IRICrIp RflATIr1RI��P��Ta��K�wf) The following benefits are subject to ERISA requirements. Please complete each column as it relates to all benefits offered by the Employer, IMPORTANT NOTE: Your Plan Document/Summary Plan Description (SPD) will be prepared based on your answers to each question so please be sure to answer these questions accurately and In agreement with the insurance certificates or summaries for these benefits. Those Insurance certificates and summaries will be Incorporated by reference in your Plan Document/SPD and in effect comprise an Important part of your Plan Document/SPD. Refer to KEYbelow for each column: Column A: Applicable health & welfare benefits subject to ERISA- Indicate by completing all columns B -G for benefits offered by Employer. Column B:! For each applicable benefit offered, enterthe Month and Date forthe ACTUAL Contract Year of the policywith each carrier. Example:Health-- Contract Year is January 1, renews everyJanuary l - Column C: Is the Contract for this benefit Issued in the group name or individual? Enter "G' for Group, or "I" for Individual, Column D: For applicable benefits offered, are employees allowed to pre-tax their contributions underyour Section 125 Plan? Enter "Y" for ves. or "N" for no. Page Employer initial G�l T03923-010117 — --