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IBI I (CI (o) (E) (Pi (G) -. Contract Benefit Contract Pre -Tax Insurance Carrier or Is Benefit 1 Total 0 of Covered Year Written to Group Benefit Service Provider Name : Self -Insured (SI), or I Participants ,.� (mo/dd/yr) I (G)orindividuais(i) II,! (Y/N); Fully-Insured(FI) (not Including Health Dental Vision Life AD&D STD LTD Voluntary/ Supplemental Life or AD&D Wellness—�-----._—..--_�._ Employee Assistance Program (EAf Stop Loss Insurance Voluntary Products Other ERISA Plans` "Other ER15A Plans: check wltu your compliance advisor to determine Lir these Plans are Employer Sponsored Plans subject to ERISA. Examples Include Prepaid Legal Services, Scholarship Funds, Day -Care Centers, Vacation Benefits, Apprenticeship orother Training Benefits, Holiday/Severance Benefits, and Housing Assistance Benefits. Is Entity part of: - a Controlled Group of Corporations under Code Section 414(b); 0 No - a Group of Businesses/Trades under common control under Code Section 414(c); or ❑ Yes (see next question) - an Affiliated Services Group under Code Section 414(m) ❑ No 4 Separate applications are required. If YES, are Benefits/Premiums paid from a single source? -❑ Yes 4 All entitles maybe under one Application. Under PPACA, current Group Health Plan is considered (selectone): ❑ Grandfathered (GF) ❑ Non -Grandfathered (NGF) _ Indicate if both Items apply below: 1. You are considered an Applicable Large Employer (ALE) under the Employer Shared Responsibility provision of the Affordable Care Act (ACT), and; O Yes ❑ No 2. You currently track employee hours to determine if any variable hour, part-time, or seasonal employees are "full- time" employees for purposes -of health plan eligibility Medicare Part D Coverage: O No ❑ Yes 4 Prescription Drug Plans, Offered_ ❑ Creditable ❑ Non- Creditable ❑ Both ADMIN ONLY: TASC ERISA -Special Instructions: ❑PCORICompliance Services (with TASC ERISA -free) PRICING ,,, No Set -Up Fee Cl PCORI Compliance Services (without TASC ERISA) INFO: • Annual Admin Fee (due now) • Based on number of emDlove (1),RESLIUl -FUR IN FUtiMATIUN- Select all that apply to your current benefits and status: ❑ (A) Health Reimbursement Account (HRA) ❑ (B) TASC HRA Client ❑ (C) TASC Non -Excepted (Health) Flexible Spending Account (NEFSA) Client ❑ (D) Self -Insured Health Plan ❑ (E) TASC HRA Self-Adm_Inistration Client /TASC Self -_Administration NEFSA Client_ If you checked ONLY boxes A and B and/or C, you can skip Part 2 below.` Page 10 Employer Initial `/''t)j�`�''',.'""°i71'ASC- TG1923-010117 - ` �II30