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Enter the following Participant counts (see Instructions below on how to count Participants): 1st day of the 1st month of your Plan Year: --._--- ----_-Part --_.. Participant 1st day of the 4th monthof your Plan Year: Part _ count as of: 1st day of the 7th month of your Plan Year: _ arta_ 1st da of rhe 10th month of our Pian Year: INSTRUCTIONS for Participant Count (based on answers in Part 1 above): Box A ONLY, Box A and E ONLY, or Box C and E ONLY BOTH Box A and D, or BOTH Box C and D Box D ONLY *Include all COBRA Participant counts should equal the total number of HRA or NEFSA Plan Participants* on the first day of each quarter during the Plan Year. . Participant counts should equal the total number of self-insured Health Plan Participants* on the first day of each quarter during the Plan Year. Count each Health Plan Participant with self -only coverage and then add to that the number of Participants with other than sel f only coverage multiplied by 2.35 (the same Plan Year is assumed for both your HRA and self-insured Health Plan). ...Part__. .._.e r- - Part__. ___-__ _.._--.. ___._._..- Participant counts should equal the total number of self -Insured Health Plan Participants* on the frst day of each quarter during the Plan Year. Count each Health Plan Participant with self -only coverage and then add to that the number of Participants with other than self only coverage multiplied by 2.35 icipants In your count but do not Include any spouses or dependents that maybe covered under the Plan. ADMIN ONLY: TASC PCORI - Special Instructions: ❑ IRS Form 5500 Preparation PRICING ! * Annual Admin Fee (due now) INFO: r Based on number of benefits (additional fee 8*) __. _.. _. _. Part. + Late Filing for Form 55007 ❑ No ❑ Yes If YES. enter number of late filings: 5500 Plans, not for customers who are getting 5500 prep with another offering, If only/ate filing ADMIN ONLY: TASC Form 5500 Prep - Special Instructions: kk�*1�5 ! rBr.K+t`''rfi3+' ^"r 3rr y i�1 e4?m en,.`Es M�i�I`m'mrs.ylt"u�,�'+'��)'dS u s- Jad.S�Z.v'�v�.'wSfi+..t1}4u'H+v`r.fJ'�t PRICING '; ' Set -Up Fee (due now) El Non -Discrimination Testing -. Annual Admin Fee (due now) INFO: Based on numberofamnlova Select aILI t at apply, an n tate t e starten ates or Plan Year to be tested: _- Start Date: End Date: ❑ Premium Only Plan (POP) (Section 125 PI an): Eligibility Test, Contributions & Benefits Test- Availability&Utilization, Key Employee Concentration Test - __—.. —)�— —)—)-- ❑ Flexible Spending Account (FSA) - Dependent Care (Section 129 Plan): Eligibility Test, Contributions & Benefits Test, More than 5% Owners Concentration Test, 55%Average Benefits Test _ ____.. _... _. -. 13 Flexible Spending Account (FSA) - Medical: Eligibility Test, Benefits Test ❑ Health Reimbursement Arrangement (HRA): Eligibility Test, Benefits Test ❑ Self -Insured Medical Plans: Eligibility Test, Benefits Test ❑ Group Term Life Insurance: Eligibility Test, Benefits Test Note: Group employees of all entities must be tested if entity Is a member of a controlled group of corporations, trades, orbusinesses under common control or on affiliated service. ADMIN ONLY: TASC Nan-Discrim Testing- Special Instructions: Page a Employer Initial TG3923-010117