TC-3923-100117 TASC Group Plan Application

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Group Business Plan ApplicationInternal Use Only: Large Client QualifierPlease submit completed Application withrequired fees 661‐9638MailTASC, c/o New Business Department2302 International Lane, P.O. Box 14140Madison, Wisconsin 53704‐3140PART 1: EMPLOYER/ADMINISTRATOR/PLAN SPONSORContact Name:Email (required):Title:Telephone:Company Name:Business Federal ID#:Physical Address: (no PO Box)City:State:Zip:Mailing Address: (no PO Box)City:State:Zip:NAICS/SIC Code:Total # Employees:Nature of Business:Total # Benefit Eligible Employees:Tax Filing Status: C‐Corp S‐Corp Partnership Sole Proprietor Non‐Profit LLC Other:Health Insurance Carrier:Carrier Group ID#:Renewal Date:Carrier AM/Rep Name:AM/Rep Email:PART 2: TASC SERVICE OFFERING SELECTIONS No Yes If Yes, please provide your 12‐Digit TASC ID#:Name existing/active TASC services:Are you a current TASC Client?Select the new TASC service offering(s) for this application (and complete each corresponding section under PART 6):Check the boxes for eachincluded offering below& complete each sectionwithin this application. TASC Suite # (1‐8)TASC Suite Add‐On Offerings (optional): Complete app section for selectionsBENEFIT ACCOUNT MANAGEMENT SERVICES FlexSystem FSA FlexSystem POP Transit Account Parking Account TASC HRA TASC HSA TASC ACA Employer Reporting TASC Non‐Discrimination Testing TASC Form 5500 PreparationBENEFIT CONTINUATION SERVICES TASC COBRA TASC FMLASECTION A QB TakeoverSECTION D Eligibility DeterminationSECTION ECOMPLIANCE SERVICES TASC ACA Employer Reporting (2‐yr contract) TASC HSA‐Full TASC HSA‐Limited TASC HSA‐Plan Only TASC HRA‐FullSECTION F TASC ERISA TASC HRA Debit Card TASC HRA‐Self TASC GiveBack PayPath* TASC Funded HRA*SECTION B Medicare Part D Notices Late 5500 Filing PPACA Notices Carrier Certificate Add Wrap Doc(s)SECTION C TASC PCORI (with TASC ERISA‐free) TASC PCORI (without TASC ERISA) TASC Form 5500 Preparation TASC Non‐Discrimination Testing TASC HIPAASECTION L*Complete separateplan application.SECTION GSECTION HSECTION ISECTION Jn/aPART 3: FEES FOR SELECTED SERVICESEnter each Service Offering selected in PART 2 and the applicable fees in the pricing chart below:One TimeSet‐Up Fees Additional Servicesand Fees New Service Offerings:TOTAL FEES:Page 1TC‐3923‐100117AdministrationFeesMinAdmin FeeAnnualRenewal FeesEmployer Initial

PART 4: BILLING AND PAYMENT INFORMATIONSelect a payment method for your fees due and complete the following information for the selected payment method.Payment Method Options:ACH (E‐Pay)1Credit Card2InvoicedSet‐Up Fees: N/ADUE NOW for all servicesAdministration, Renewal,and Additional Fees: Not Available Admin Fees DUE NOW for: TASC HIPAA, ACA, POP, Self‐HRA ALL FEES DUE NOW for TASC ERISAInformation for Payment MethodsACH (E‐Pay) Information:Financial Institution Name:Bank Routing # (9 digits):Routing and account numbers are typically located at the bottom left corner of a blank check from your bank (varies).The routing number is always nine (9) digits long and enclosed by colons. MasterCardCredit Card Information:State:Checking Acct #: Visa American Express DiscoverCard #:Name on Card:Exp. Date: Signature:Frequency: Quarterly Annually (1‐15 Employees defaults to Annually) Same address from Section 1Invoice Information:Mail to:Billing Contact Name:Email:Street Address: City: Different address: State:Zip:1E‐Pay is TASC’s standard method for submission of administration fees. With E‐Pay, TASC conveniently deducts your fees from your checking account. Simplycomplete the box above, signing where indicated. Please note ACH information for each benefit's plan funding will need separate attention in their respective sectionof the application. All written debit authorizations must agree that the Payer may revoke the authorization only by first notifying the Originator in the mannerspecified in the authorization. The language in the authorization represents the disclosure requirement associated with the clarification of OFAC economic sanctionpolicies upon ACH Network Participants.2Credit Card payment option is only available for fees submitted with this completed Plan Application. It is not available for future billing payments.PART 5: AUTHORIZATIONThis Group Plan Application is a binding agreement between Total Administrative Services Corporation (“TASC”) and you and, if applicable, thecompany or other legal entity you represent (collectively, “you”). By signing this Group Plan Application below, you accept the terms of the ServiceLevel Agreement. You also accept the TASC HIPAA Privacy offering as indicated in Part 2 above for applicable service offerings and youacknowledge receipt of the attached HIPAA Business Associate Agreement signed by TASC that assures compliance for your records.Further, you, as Plan Sponsor and Plan Administrator, and on behalf of, the plan set forth in this Group Application, hereby appoint TASC and/or itssubcontractors or agents to act as an authorized agent for purposes of receiving and/or retrieving electronic reports/responses (“Claim FeedInformation”) from the insurance carrier(s) listed in this Group Application or otherwise identified by you on your behalf. TASC and/or itssubcontractors or agents use and disclosure of Claim Feed Information shall be subject to the terms of the Business Associate Agreement.I have read, understand and agree to the terms and conditions stated in this Group Plan Application, the Service Level Agreement, and theBusiness Associate Agreement (if applicable), as attested by the signature below, effective on the date of the signature. Employer Signature:Date:Title:Distributor/Agent Name:MyTASC Provider ID #:Primary Account Rep Name:Email:INTERNAL USE ONLY:Assist MyTASC ID:Page 2TC‐3923‐100117Employer InitialRetail Code:

PART 6: INFORMATION FOR SELECTED SERVICE OFFERINGSTo conclude this application, please complete each Section below for the service offerings selected in PART 2 of this application.For a TASC Suite, complete each section for the service offerings included in the Suite.SECTION A: FLEXSYSTEMSelect the FlexSystem Plan(s) you are applying for and enter the requested information where indicated for each selected Plan: Flexible Spending Account (FSA) Full AdministrationPRICING INFO: Set‐Up Fee (due now) Admin Fee – per participant, per month Annual Renewal Fee Premium Only Plan (POP) AdministrationPRICING INFO: Admin Fee – per group, per year (due now)PRICING INFO: No additional fee w/FlexSystem Full FSA Admin Fee – per participant, per month Annual Renewal FeePOPTransit Account Transit Reimbursement Account (T/P) Parking Reimbursement Account (T/P)PLAN INFORMATIONNumber of Eligible Employees (each):Existing Plan in Place?Full FSA No Yes No Yes Parking Account No Yes No Yes If YES, please complete the following: ERISA 3‐Digit Plan #:# of Current Participants:Name of Current Administrator:N/AN/APLAN OPTIONSFSASelect options below and enter the information for yourapplicable current and new Plan(s): Healthcare FSA Carryover (default 500) Grace Period (default 2.5 months): If Health Carryover isalso elected, Health FSA will be excluded from Grace Period. Runout Period (default 90 days after Plan End Date)Runout for all benefits end on same dateCurrent PlanT/PNEW PlanCarryover :Carryover :GP End Date:/ /GP End Date:/ /RO End Date:/ /RO End Date:/ /Select administrator for current FSA Plan Grace Period and Runout: Prior Administrator TASC11IMPORTANT:Obtain the FlexSystem Takeover Checklist for information that must be received before Plan start date with TASC. Carryover data from a prior Administratormust be provided to TASC after the prior Plan Year Runout has ended with the applicable funding.AVAILABLE FSA PLAN TYPESFSAPOPSelect all benefits made available to the eligible employee(s). These benefits are taken through salary deductions. Healthcare FSA ‐ Medical Expense Reimbursement Account: Maximum Election (Employee & Family)Is employer‐sponsored group health insurance offered to employees? Yes No If NO, you are not eligible to offer this benefit. Dependent Care FSA Reimbursement Account: Maximum 5,000; 2,500 if married filing separately (Employee & Family) Non‐Employer Sponsored Premium Reimbursement (NESP): For Qualified Individual Premium Plans not offered through any employer.Is employer‐sponsored group health insurance offered to employees? Yes No If NO, you are not eligible to offer this benefit. Medical or Medical‐Related Premium: Group Sponsored (Employee & Family) Voluntary/Group Term Life Insurance Premium: Up to 50,000 in death benefits (Employee Only) Disability Insurance Premium: Pre‐taxing employee contributions will make benefit taxable compensation (Employee Only) Supplemental Insurance: Includes cancer, hospital confinement, intensive care, accidental death and dismemberment (Employee & Family)IRS ALLOWED AUTO‐SUBSTANTIATED CO‐PAYS Medical/Office: FSA Prescription Drug: ADMINISTRATIVE OPTIONS for TRANSIT/PARKINGT/PIf applicable, select options below for your TASC Transit and/or Parking Account. Defaults are based on the current IRS monthly maximum.Each option can be selected for either or both benefits, EXCEPT the Terminal Restricted Card must apply to both accounts. RolloverPage 3TC‐3923‐100117Transit Account Reimbursement Restriction:Days (180 default) RolloverParking Account Reimbursement Restriction:Days (180 default) Terminal Restricted Card(applies to both Transit and Parking)Employer Initial

PLAN CONTRIBUTIONSEmployer Contributions?Payroll/Funding Cycle (select one):# Contributions in 12‐mo Plan Year:FSA No Yes Weekly Bi‐Weekly Semi‐Monthly MonthlyT/P Other:Dates applied to Participant accounts based on above selected payroll cycle.Participant Contribution Schedule:st1 Contribution:(based on Plan Funding schedule below forthe Estimated Date of Receipt (EDR))/ /2nd Contribution:/ // /Last Contribution:Other cycles:PARTICIPANT AND ELIGIBILITY REQUIREMENTSFSAPOPT/PEntry and Probationary Period:Select the employment requirement below that an eligible employee must meet in order to enroll in theFlexSystem Plan at open enrollment, or at the time of hire: On the date of hire30 days after date of hire60 days after date of hire90 days after date of hire1st of the month after date of hire1st of the month after 30 days of continuous employment1st of the month after 60 days of continuous employmentOther:IncludedExcluded . . . . . . . . Additional Requirements:(select all that apply)N/A . Members of bargaining units . Part‐time employees regularly scheduled to work at least hours per week . Seasonal employees regularly working at least months within a year . Employees under years of agePLAN STARTFSAPOPT/PSelect and complete one of the following options to indicate the Plan Year dates and when FlexSystem administration begins:1st Year Administration2nd and Successive Years Initial Plan Year (no prior Plan exists)Plan Start Date: First day of: / (mo/yr)# Consecutive Months Continued:First day of: / (mo/yr)Twelve (12) month periodNote: Plans need not run on the calendar year (i.e. January 1 ‐ December 31) Renewal Date Administration (TASC administration begins on Plan renewal date)Plan Start Date: First day of: / (mo/yr)# Consecutive Months Continued: Twelve (12) month periodPlan Start Date Mid‐Year Plan TakeoverCurrent TPA Plan: / / (mo/dd/yr)TASC FlexSystem Plan:/ / (mo/dd/yr)Plan End Date/ / (mo/dd/yr)N/APLAN FUNDINGFSAT/PThis Section defines the Estimated Claims Fee (ECF) method utilized to make benefit payments to your FlexSystem Participants. The ECF is calculated by determiningthe total contributions for the Plan Year (employee and employer) and divide that total by the number of payments scheduled under the Expected Date of Receipt(EDR). This fee is adjusted as applicable for mid‐year enrollment and election changes. If the total ECF collected for the Plan Year results in excess fees greater thanpaid claims for that Plan Year, the excess will be returned to the Plan Sponsor as forfeiture under the Plan. Any fees or charges described in this section are inaddition to the fees due under Part 2: TASC Services and Fees.To start this process: (1) choose funding process, (2) verify your Expected Date of Receipt, and (3) enter your bank information:(1) TASC ACH (default): Client MyTASC Funding: (2) Verify your Expected Dateof Receipt (EDR): (3)Bank Information:TASC initiates funding payment via ACH on the EDR.Client initiates funding payment via MyTASC on or before the EDR. Note: Under this option, TASC will use your Accountand Routing Numbers to post any unpaid funding amounts that are one (1) business day past the EDR. Also, additionalannual fee will apply if ACH is not elected ( 10.00 per payroll).EDR is the payroll contribution schedule indicated in the Plan Contribution section for each payroll cycle. This is the datethat TASC will pull an Auto ACH from your designated account and apply the payroll contributions to your Participant’saccount(s). This may or may not be the same date as the Participant’s payroll deduction date. Use same ACH info from Part 4 of this ApplicationFinancial Institution Name:Bank Routing Number (9 digits): Use different ACH information as per below:State:Checking Account #:ADMIN ONLY: FlexSystem ‐ Special Instructions:Page 4TC‐3923‐100117Employer Initial

SECTION B: TASC HSA (HEALTH SAVINGS ACCOUNT)Select one TASC HSA Plan to apply for and complete the requested information for that Plan Type (as noted by corner tabs): HSA Full AdministrationPRICING INFO: HSA Limited Plan AdministrationPRICING INFO: HSA Plan‐Only AdministrationPRICING INFO:PLAN INFORMATIONNumber of Eligible Employees:Existing Health FSA in place? Set‐Up Fee (due now)Admin Fee – per participant, per monthSet‐Up Fee (due now)Admin Fee – per participant, per month (No Minimum)Set‐Up Fee (due now)No Admin FeeFULL No Yes If YES, indicate the Plan Type: LIMITEDPLAN ONLYExisting HSA in place? No YesLimited Health FSALimited Post‐Deductible Health FSAGeneral Purpose Health FSA Limited Health FSAGeneral Purpose Health FSA Limited Post‐Deductible Health FSANote: If you implement an HSA on a different Plan effective date than your existing Health FSA then you must amend your entire Health FSA to a Limited or Limited Post‐Deductible Health FSA. Amend the Plan by downloading and completing the adoption of the TASC Plan Document as instructed in your Welcome Kit. All participants aremoved to the amended Health FSA. The IRS will not allow mid‐year participant election changes. At your next open enrollment you can offer Health FSA options.PLAN CONTRIBUTIONS# of EE Payroll Contributions:Payroll/Funding Cycle:Participant Contribution Schedule:FULL Weekly Bi‐Weekly Semi‐Monthly MonthlyLIMITED Other:Dates applied to Participant accounts based on above selected payroll cycle:1st Contribution:/ /2nd Contribution:/ /Last Contribution:/ /Employer Contributions?: No Yes If YES, please complete all information below:Contribution Amount per Coverage Level: Single: Family: One Time:Contribution Date:Frequency of Employer Contributions: Weekly Bi‐Weekly Semi‐Monthly Monthly 1st Contribution:2nd Contribution:Employer Contribution Schedule:/ // /For banking holidays, select one option: Apply contributions next business day Apply contributions prior business day No YesIf YES, select a method below:Pro‐Rated for Mid‐Year Enrollees?: As of Plan Start Date As of Most Recent Quarter Other:PLAN STARTHSA Plan Start Date:FULL/ (mo/dd)HSA Plan End Date:LIMITEDPLAN ONLY/ (mo/dd) ‐‐ if applicablePLAN FUNDINGFULLTo fund your HSA Plan, TASC will initiate ACH debits from the bank account and financial institution named below. Plan funding payments will beelectronically deducted from the indicated bank account and automatically submitted on your scheduled payroll contribution dates. Use same ACH info from Part 4 of this Application Use different ACH information as per below:Bank Information:Financial Institution Name:Branch:Bank Routing Number (9 digits):Checking Account #: I understand the pay dates can NOT be changed once the Plan is enrolled. I understand TASC will send an email prior to withdrawing funds for my account and that I should contact TASC with anychanges no later than three (3) days prior to the employee’s payroll date.Disclaimer for a stand‐alone HSA Plan (not combined with TASC FlexSystem): TASC has developed a service known as “TASC HSA” that provides fulladministrative services for Health Savings Accounts. It is understood that the client wishes to add the HSA to its current Section 125 Plan and that the clientacknowledges they have amended their Section 125 Plan to include the required HSA language to allow HSA contributions to be pre‐taxed and their Section125 Plan Documents and SPD’s are current according to Federal Law.ADMIN ONLY: TASC HSA ‐ Special Instructions:Page 5TC‐3923‐100117Employer Initial

SECTION C: TASC HRA (HEALTH REIMBURSEMENT ARRANGEMENT)Select one TASC HRA Plan to apply for and complete the requested information for that Plan Type (noted by corner tabs): TASC HRA Full AdministrationPRICINGINFO:Additional Services: TASC Debit Card (included at no charge for First Dollar Plans)PRICINGINFO: TASC HRA Self‐Administration Set‐Up Fee (due now) Admin Fee – per participant, per month Annual Renewal Fee No Set‐Up Fee Admin Fee – per group, per year (due now) Annual Renewal FeePLAN INFORMATIONEstimated Number of Participants:Number of Employees (FT PT) to determine CMS Reporting Requirement:Existing HRA Plan in Place? No Yes If YES, please provide the following information:ERISA 3‐Digit Plan #:# of Current Participants:Name of Current Administrator:Current Run‐Out Period: DaysWho will administer current Plan Runout? Prior Administrator TASCPARTICIPANT AND ELIGIBILITY REQUIREMENTSFULLFULLSELFSELFSelect one eligibility requirement below: Eligibility requirements include participation in the named Health Insurance Plan (N/A for Qualified Small Employer HRA Plans); or Eligibility requirements include (select all that apply below): Part‐time employees working at least hours of work per week will be included (maximum 29 hours) Current employees completing months of service with the employer will be included (maximum 90 days) New employees completing months of service with the employer will be included (maximum 90 days) Eligibility requirements – OTHER:PLAN DESIGNFULLSELFEach Plan Design selected requires a separate Plan Application. Administration fees and funding arrangements apply to each Application.Budget Plan FundingHRA Plan Design Options (select one per Application)The TASC Budget Plan Funding Fee is calculatedAt 25% Plan 1: Medical Deductible Onlyas a percent of the aggregate annual benefitunder the TASC HRA Plan. To calculate plan Plan 2: Medical Deductible & PrescriptionAt 50%(also applies to Deductible Only Plans; prescriptions apply toward the deductible) Plan 3: Medical Deductible & Co‐Insurance Plan 4: Medical Deductible, Co‐pay, & Prescription Plan 5: Medical Deductible, Co‐Pay, Co‐Insurance, & Prescription Plan 6: Uninsured Medical (must be integrated with GHP)Plan 7: QSEHRA Uninsured MedicalPlan 8: QSEHRA Medical Insurance PremiumsPlan 9: QSEHRA Uninsured Medical & Individual Insurance Premiums funding take Total Exposure x Funding % / 12months.At 50%At 50%At 50%At 50%At 50%At 75%At 75%If you do not see your desired Plan Design,please call TASC at 1.800.422.4661 to discussPlan setup.HRA REIMBURSEMENTSFULLTASC HRA Plan Participant Responsibility:(amount participant is responsible for prior to reimbursements)Individual: Family Maximum: PercentageTASC HRA/Employer Reimbursements:%%%% Max. reimbursement per Individual: Max. reimbursement per Family:Page 6TC‐3923‐100117 by Member (embedded deductible) by Family AggregateDollar Amount Range SELF‐‐‐‐ TASC HRA/Employer Reimbursed by Member (embedded deductible) by Family AggregateEmployer Initial

PLAN STARTFULLSELFSelect and complete one of the following two options. Indicate the Plan Year dates and when TASC HRA administration begins.1st Year Administration2nd and Successive Years New HRA Plan (no current plan exists)Plan Start Date: # Consecutive Months Continued:First day of: / (mo/yr)First day of: / (mo/yr)Twelve (12) month periodNote: Plans need not run on the calendar year (i.e. January 1 ‐ December 31) Mid‐Year Plan Takeover – select one setup option below (Year‐to‐Date balances must be submitted with enrollments in order to be entered):Plan Sponsor must submit an aggregate balance report of participant claims paid year‐to‐dateto adjust the Participant HRA balance Short Plan Year setup: (less than 12 months) Plan Sponsor must submit an aggregate deductible credit report of participant claims paidyear‐to‐date to adjust the Participant HRA balance. Allows you to extend a deductible credit toyour Participants based on the amount of the health insurance deductible that has beensatisfied thus far. Full Plan Year setup; or Enter plan dates based on your selected setup:Current TPA Plan:TASC HRA Plan:Plan Start DatePlan End Date/ / (mo/dd/yr)/ / (mo/dd/yr)/ / (mo/dd/yr)N/APLAN FUNDINGFULLTo fund your TASC HRA Plan, TASC will initiate ACH debits from the financial institution and bank account named below. Use same ACH info from Part 4 of this Application Use different ACH information as per below:Bank Information:Financial Institution Name:Branch:Bank Routing Number (9 digits):Checking Account #:ADMIN ONLY: TASC HRA ‐ Special Instructions:Funding: % (Minimum of 25%)SECTION D: TASC COBRA COBRA Administration & ComplianceNOTE: The Premium Collection Form is required with completed application before Plan can be setup.Additional Services (additional fees apply): Takeover Qualified Beneficiaries (TQB) COBRA Enrollees: #PRICINGINFO: Set‐Up Fee (due now) Admin Fee – per HE, per month Annual Renewal Fee(Submit Takeover Qualified Beneficiary Form(s) for each TQB with completed application)PLAN INFORMATIONNumber Employees on Health Insurance Plan:(Current count needed for billing purposes)Total Number of Employees (pro‐rate for PT):Current COBRA Administrator: Self Other:SUBSIDIARIES, AFFILIATES, or DIVISIONSIdentify all subsidiaries, affiliates, or divisions to include under TASC COBRA and if they require a separate setup for service communications:Name:SeparateName:Separate1) 3) 2)4)PLAN STARTEnter the month and year that the Plan Year will start for the first year of TASC COBRA administration:TASC COBRAPlan Start Date:First day of: / (mo/yr)COBRA Period Begins: First of month, following qualifying event Day after qualifying eventPlan Application must be received by 15th of month prior to this start date.COBRA Addendum is needed if requested plan start date does not meet this requirement. Other (please specify below):ADMIN ONLY: TASC COBRA ‐ Special Instructions:Page 7TC‐3923‐100117Employer Initial

SECTION E: TASC FMLA Set‐Up Fee (due now) Admin Fee – per employee, per month(No Minimum) Annual Renewal Fee FMLA Administration & ComplianceAdditional Services (additional fees apply): FMLA Eligibility & Entitlement Determination (free of charge within a TASC Suite)Select one: Submit eligibility file per month Submit eligibility file per eventPLAN INFORMATIONNumber of Employees:Number of EES currently on FMLA Leave:PRICINGINFO:Number of Company Locations:Enter Location Name(s):(additional fees apply per takeover at implementation)Current FMLA Administrator (enter below): Self TPA:FMLA to run concurrent with WorkersCompensation and Short‐term Disability Plans:Method of Reporting FMLA Hours:FMLA 12‐month Tracking Type (select one):PLAN STARTTASC FMLA Plan Start Date:Enter any States doing commerce:Reporting per Location?: No Yes (next question) YesIf YES, enter locations and contacts: No Manual Report (via online form) Data Feed (via recurring file from your timekeeping system for FMLA time used) Rolling Backward Calendar Year Rolling Forward Plan Year w/Start Date of / // (mo/dd)Plan Application must be received 10 days prior to this start date.ADMIN ONLY: TASC FMLA ‐ Special Instructions:SECTION F: TASC ACA EMPLOYER REPORTING ACA Employer Reporting (2‐year contract required)PRICINGINFO: Set‐Up Fee (due now) Annual Admin Fee (due now)REQUIRED: Please select your Employer type and the appropriate service offering selection for your ACA Reporting needs:Employer Type Single ALE or Government Entity (one EIN): Aggregated ALE (more than one EIN):Controlled Group or Government Entity Non ALE (under 50 FT employees):IT Employer InformationContact Name:Telephone:Level of Service Needed Comprehensive Plan (includes Variable Hour Tracking) Reporting Only Comprehensive Plan (includes Variable Hour Tracking) Reporting OnlyEmployee Mandate OnlyEmail:File Frequency: Monthly File Per Payroll FileALE Status InformationApplicable Large Employer (ALE) Status: ALE with Insured Medical Plan ALE with Self‐Insured Medical Plan Non‐ALE with Self‐Insured Medical Plan (1094B and 1095B Filing) no further info needed.Medical Plan Dates (for previous selection):If you are a “NON‐ALE” with Self‐Insured Medical Plan, you DO NOT need to provide the information below.Plan Information and ServicesPlease indicate whether you will be including the optional services below (response required for pricing):Variable Hour Tracking: Yes NoMinimum Essential Coverage offer indicator:The TASC ACA Employer Reporting Administration Manual will help you answer any of the following items that youhave not already determined. Select only those that apply (leave blank if unsure):Page 8TC‐3923‐100117Employer Initial Yes No Qualifying Offer Method 98% Offer Method

Aggregated ALE InformationControlled Group: Please indicate if you are a member of any of the following: (required) 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(o)Government Entity: Are you are a 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 theAggregated ALE, placing the entity with the most employees on top descending down to the entity with the fewest employees. A PlanApplication will need to be submitted separately for each entity.Entity’s Legal NameEntity’s EIN NumberIf there are more than 15 entities to report, please provide the remainder on an additional document.ADMIN ONLY: TASC ACA ‐ Special Instructions:SECTION G: TASC ERISA ERISA Compliance ServicesPRICINGINFO:NOTE: Plan will begin on the first of the month in which application is received.Additional Services (additional fees apply): Medicare Part D Notice1 PPACA Notices1 Additional Benefit Plans (9 ) Professional Services (billed hourly) Carrier Certificates of Coverage attached to Plan Document/SPD Set‐Up Fee (due now) Annual Admin Fee (No Minimum) (due now) Form 5500 Late Filing (# of years to be filed: ) Wrap Document2 ‐ Individual/Separate Affiliated Employer1Services automatically renew annuallyOnly select if additional Wrap Documents are needed beyond included Mega‐Wrap Document2BENEFITS INFORMATIONThe 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 besure to answer these questions accurately and in agreement with the insurance certificates or summaries for these benefits. Those insurancecertificates and summaries will be incorporated by reference in your Plan Document/SPD and in effect comprise an important part of your PlanDocument/SPD. Refer to KEY below 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, enter the Month and Date for the ACTUAL Contract Year of the policy with each carrier.Example: Health ‐‐ Contract Year is January 1, renews every January 1Column 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 under your Section 125 Plan?Enter “Y” for yes, or “N” for no.Page 9TC‐3923‐100117Employer Initial

(A)(B)ContractYear(mo/dd/yr)(C)Benefit ContractWritten to Group(G) or Individuals (I)(D)Pre‐TaxBenefit(Y/N)(E)Insurance Carrier orService Provider Name(F)Is BenefitSelf‐Insured (SI), orFully‐Insured (FI)(G)Total # of CoveredParticipants(not TDVoluntary/ Supplemental Life or AD&DWellnessEmployee Assistance Program (EAP)Stop Loss InsuranceVoluntary ProductsOther ERISA Plans**Other ERISA Plans: check with your compliance advisor to determine if these Plans are Employer Sponsored Plans subject to ERISA. Examples include Prepaid LegalServices, Scholarship Funds, Day‐Care Centers, Vacation Benefits, Apprenticeship or other Training Benefits, Holiday/Severance Benefits, and Housing Assistance Benefits.GROUP HEALTH PLAN INFORMATIONIs Entity part of: No Yes

SECTION C TASC PCORI (with TASC ERISA‐free) TASC PCORI (without TASC ERISA) SECTION H TASC GiveBack SECTION L TASC Form 5500 Preparation SECTION I PayPath* *Complete separate plan application. TASC Non‐Discrimination Testing SECTION J TAS

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