Laserfiche WebLink
Group Services Plan Application <br /> �.. ICI! p PP <br /> Please submit your completed Plan Application with enrollment fee to: E -mail: newbusiness @tasconline.com Fax: 608 - 661 -9638 <br /> Mail: TASC, c/o New Business Department <br /> Internal Use Only: ❑ Large Client Qualifier 1 2302 International Lane, P.O. Box 14140, Madison, Wisconsin 53704 -3140 <br /> (1) EMPLOYER /ADMINISTRATOR <br /> Check all that apply: ® FlexSystem ❑ HSA ❑ DirectPay ❑ COBRAToday ❑ FMLAMatters ❑ PayPath ❑ ERISAEdge <br /> Contact Name Dallas Larson Title Administrator <br /> Company Name City of Centerville E-mail (Required) dlarson @centervillemn.com <br /> Company Physical Address (not PO Box) 1880 Main St. City Centerville State MN Zip 55038 <br /> Mailing Address —if different from Physical address City State Zip <br /> Phone Number (651) 429 -3232 Fax Number (651) 429 -8629 <br /> Business Federal ID # 41-1267014 NAICS or SIC Code 9199 <br /> Tax Filing Status: ❑ C -Corp ❑ S -Corp ❑ Partnership ❑ Sole Proprietor ❑ Non - Profit ❑ LLC g Other Government <br /> Nature of Business City Government <br /> Do you own an interest in any other business? ❑ Yes ® No <br /> If you are a current client of TASC, please provide your 12 -Digit TASC ID# 4301 - 8353 -4013, BR95 <br /> Current TASC service: ❑ FlexSystem ❑ HSA ❑ DirectPay g COBRAToday ❑ FMLAMatters ❑ PayPath ❑ ERISAEdge <br /> Name of Health Insurance Carrier Health Partners Carrier Group ID# Renewal Date <br /> Name of Carrier Account Manager /Rep AM /Rep Email <br /> (2) PAYMENT /BILLING INFORMATION <br /> The Enrollment Fee is due at the time of application. (South Dakota residents add 4% sales tax.) <br /> Service Initial Set -up Minimum Per Participant Annual Renewal Fee Other Fees I <br /> Fee Monthly Fee Fee (For groups with 1 -500 employees this <br /> fee will default to a minimum of $100 <br /> unless noted otherwise.) <br /> Flexsystem J $ 275 ( $ 30 $ 5 $ 50 <br /> TASC HSA (Full Service) $ i $ $ $ HSA (Limited or Plan Only) <br /> 4 ___ _._._. I $ <br /> DirectPay V $ __ _ �_ ( $ _ $ Benefits Card $ <br /> COBRAToday $ — $ E $ $ TQB $ <br /> # of TQBs <br /> H ers ' $ $ $ $ Active Assumption $ <br /> _ Eligibility Determination $ <br /> e $ $ S <br /> $ $150 /hr <br /> nnual fee, Late 5500 Filing $ <br /> s are application) HCR Notices $ <br /> 105(h) Test $ <br /> $ $ $ $ <br /> TOTAL $ ❑ Check here if you want TASC to ACH your initial set -up fees. (Fill in E - Pay information.) <br /> g Check # (Make check payable to TASC) ❑ MasterCard ❑ Visa ❑ American Express ❑ Discover <br /> Signature Name of Cardholder (Name on Card) <br /> Card # Exp. Date <br /> TC- 3923 - 080111 Employer Initial , I�TASC <br /> 15 <br />