GROUP BUSINESS PLAN APPLICATION

Address

TASC COBRA
DO YOU HAVE TAKEOVER QUALIFIED BENEFICIARIES?
PREMIUM COLLECTION FORM
TAKEOVER QUALIFIED BENEFICIARY FORM(S)
DO YOU HAVE ADDITIONAL SUBSIDIARIES, AFFILIATES, OR DIVISIONS TO INCLUDE UNDER TASC COBRA?
HOW MANY SUBSIDIARIES, AFFILIATES, OR DIVISIONS DO YOU HAVE?
NAME
NAME
NAME
NAME
DO THEY REQUIRE SEPERATE SETUP FOR SERVICE COMMUNICATIONS?
COBRA PLAN START DATE

- Month - Day Year
WHEN THERE IS A COBRA QUALIFYING EVENT WHEN WOULD YOU LIKE THE COBRA PERIOD TO BEGIN?

FIRST OF THE MONTH, FOLLOWING THE QUALIFYING EVENT DAY AFTER QUALIFYING EVENT
SPECIAL INSTRUCTIONS

TASC PCORI
PLEASE SELECT ALL THAT APPLY TO YOUR CURRENT BENEFITS AND STATUS:

HEALTH REIMBURSEMENT ACCOUNT (HRA) TASC HRA CLIENT TASC NON-EXCEPTED HEALTH FLEXIBLE SPENDING ACCOUNT (NEFSA) CLIENT SELF-INSURED HEALTH PLAN TASC SELF ADMINISTERED HRA OR NEFSA CLIENT
PARTICIPANT COUNT AS OF THE 1ST DAY OF THE 1ST MONTH OF YOUR PLAN YEAR
PARTICIPANT COUNT AS OF THE 1ST DAY OF THE 4TH MONTH OF YOUR PLAN YEAR
PARTICIPANT COUNT AS OF THE 1ST DAY OF THE 7TH MONTH OF YOUR PLAN YEAR
PARTICIPANT COUNT AS OF THE 1ST DAY OF THE 10TH MONTH OF YOUR PLAN YEAR
INSTRUCTIONS FOR PARTICIPANT COUNT:

IF YOU SELECTED BOX A ONLY, BOX A AND E ONLY, OR BOX C AND E ONLY: PARTICIPANT COUNTS SHOULD EQUAL THE NUMBER OF HRA OR NEFSA PLAN PARTICIPANTST ON THE FIRST DAY OF EACH QUARTER OF THE PLAN YEAR.

IF YOU SELECTED BOTH BOX'S A AND D, OR BOTH BOX'S C AND D? PARTICIPANT COUNTS SHOULD EQUAL THE TOTAL NUMBER OF SELF-INSURED HEALTH PLAN PARTICPANTS ON THE FIRST DAY OF EACH QUARTER DURING THE PLAN YEAR. COUNT EACH HEALTH PLAN PARTICIPANT WITH SELF-OLNLY COVERAGE AND THEN ADD TO THAT THE NUMBER OF PARTICIPANTS WITH OTHER THAN SELF-ONLY COVERAGE MULTIPOLED BY 2.35.

IF YOU SELECTED BOX D ONLY: PARTICIPANT COUNTS SHOULD EQUAL THE TOTAL NUMBER OF SELFINSURED HEALTH PLAN PARTICIPANTS ON THE FIRST DAY OF QUARTER OF 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 MULTIPLED BY 2.35.

TASC HIPAA
THANK YOU FOR CHOSING TASC HIPAA SERVICES. NO FURTHER INFORMATION IS NEEDED AT THIS TIME. PLEASE HIT THE NEXT BUTTON TO CONTINUE WITH THE APPLICATION PROCESS.

TASC GIVEBACK
PLAN START DATE

- Month - Day Year
PLAN BENEFIT OFFERINGS:

COMPANY MATCH ENROLLMENT BONUS HOLD A FUNDRAISER
EMPLOYEE MATCH PER EMPLOYEE PER YEAR:
EMPLOYEE MATCH PER PAYROLL
COMPANY ENROLLMENT BONUS AMOUNT:
COMPANY ENROLLMENT BONUS AMOUNT:
NUMBER OF EMPLOYEE CONTRIBUTIONS IN A 12-MONTH PLAN YEAR?
PAYROLL/FUNDING CYCLE

WEEKLY BI-WEEKLY SEMI-MONTHLY MONTHLY
PARTICIPANT CONTRIBUTION SCHEDULE:
1ST CONTRIBUTION

- Month - Day Year
2ND CONTRIBUTION

- Month - Day Year
LAST CONTRIBUTION

- Month - Day Year
FUNDING OPTION (SELECT ONE)

TASC AUTOMATIC CHECK PROCESSING (ACH) CLIENT INITIATED FUNDING ($10.00 FEE PER PAYROLL)
BANKING INFORMATION:

Banking information is needed to fund the plan on the specified contribution dates.
NAME OF FINANCIAL INSTITUATION
BANK ROUTING NUMBER
BANK ACCOUNT NUMBER
SPECIAL INSTRUCTIONS

BANKING INFORMATION:

PLEASE PROVIDE THE BANK ACCOUNT INFORMATION THAT TASC WILL USE FOR SERVICE FEES.
NAME OF FINANCIAL INSTITUATION
BANK ROUTING NUMBER
BANK ACCOUNT NUMBER
BILLING SPECIAL INSTRUCTIONS:

	ONE TIME SET-UP FEES	ADMINISTRATION FEES	ADDITIONAL SERVICES AND FEES
FEES

	ONE TIME SET-UP FEES	ADMINISTRATION FEES	MINIMUM MONTHLY ADMIN FEES	ADDITIONAL SERVICES AND FEES
FEES

	ONE TIME SET-UP FEES	ADMINISTRATION FEES	ANNUAL RENEWAL FEES	ADDITIONAL SERVICES AND FEES
FEES

	ONE TIME SET-UP FEES	ADMINISTRATION FEES	ADDITIONAL SERVICES AND FEES
FEES

	ADMINISTRATION FEES	ADDITIONAL SERVICES AND FEES
FEES

	ADMINISTRATION FEES	ANNUAL RENEWAL FEES	ADDITIONAL SERVICES AND FEES
FEES

	ONE TIME SET-UP FEES	ADMINISTRATION FEES	ANNUAL RENEWAL FEES	ADDITIONAL SERVICES AND FEES
FEES

	ADMINISTRATION FEES	ADDITIONAL SERVICES AND FEES
FEES

	CONTRACT YEAR	BENEFIT CONTRACT WRITTEN TO GROUP OR INDIVIDUALS (G OR I)	PRE-TAX BENEFIT	INSURANCE CARRIER NAME	SELF INSURED OR FULLY INSURANCE	TOTAL # OF COVERED PARTICIPANTS (NOT INCLUDING DEPENDENTS
HEALTH
DENTAL
VISION
LIFE
AD&D
STD
LTD
VOLUNTARY/SUPPLEMENTAL LIFE
WELLNESS
EMPLOYEE ASSISTANCE PROGRAM
STOP LOSS INSURANCE
VOLUNTARY PRODUCTS
OTHER ERISA PLAN

PROVIDER INFORMATION