2012-09-26 CC Packet - Laserfiche WebLink

Home Browse Search

(3) E-PAY Frequency of Invoicing: ❑ Quarterly ❑ Annually ® 1 -15 Employees (default to Annually) ❑ Send Administration Fee Invoice to different address. Billing Contact Title Address City State Zip Telephone Number E -mail (Required) E -Pay is TASC's standard method for submission of administration fees. With E -Pay, TASC conveniently deducts your fees from your checking account. Simply complete the following, signing where indicated. All written debit authorizations must agree that the Payer may revoke the authorization only by first notifying the Originator in the manner specified in the authorization. The language in the authorization represents the disclosure requirement associated with the clarification of OFAC economic sanction policies upon ACH Network Participants. Financial Institution Name State - 1 _ i_ 1 I _ _ � _ I Bank Routing Number Checking Account Number To determine your routing number, refer to your check. The routing number is always nine digits long and it is enclosed by colons. While the location of the routing and account numbers on your check varies depending on your bank, it is often printed in the bottom left corner. (4) AUTHORIZATION This Group Plan Application is a binding agreement between Total Administrative Services Corporation ("TASC") and you and, if applicable, the company or other legal entity you represent (collectively, "you "). By signing this Group Plan Application, you accept the terms of the Service Level Agreement. If this Group Plan Application is for full FlexSystem, TASC RSA, DirectPay HRA, COBRAToday, FMLAMatters, ERISAEdge, and /or PayPath plan administration, you acknowledge receipt of the HIPAA business associate terms and conditions provided to you with this Group Plan Application ( "Business Associate Agreement "), and you agree to be bound by the terms and conditions, as stated therein, of the Business Associate Agreement. A copy of the Business Associate Agreement must be returned with this completed Group Plan Application. 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 its subcontractors or agents to act as an authorized agent for purposes of receiving and /or retrieving electronic reports /responses ( "Claim Feed Information ") from the insurance carrier(s) listed in this Group Application or otherwise identified by you on your behalf. TASC and /or its subcontractors 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 the Business Associate Agreement (if applicable), as attested by the signature below, effective on the date of the signature. X Employer (sign here) Title City Administrator Date 9 - 20 - 12 1 certify that the names listed below have HIPAA Business Associates Agreements with our company and are authorized to access information on our behalf. Name Allan Roth Name Dan Reynoso Name Bill Singer Provider /Agent Name A.T. Grou Provider /Agent Number 163298891 Retail Code Primary Account Representative of Provider /Agent Name Stephanie Roth E - mail Stephanie.roth @at- group.net (5) FLEXSYSTEM FlexSystem Administration Options (Check only one): g FSA ❑ SIMPLE FSA ❑ POP (only fields with *) *Total number of eligible employees 11 Specify all applicable payroll cycles (12, 24, 26, etc) 24 Number of payrolls in first year � Number of pre -tax deductions in a typical 12 month Plan Year 24 *Do you currently have a Section 125 Plan? ❑ Yes ® No If yes, indicate the following: Type of Plan: ❑ FSA ❑ POP List ERISA Plan Number Number of Participants 1 Name of Administrator If you have a current FSA, indicate who will administer the Plan's Grace and Run Out: ❑ Prior Administrator ❑ TASC Prior Plan Year New Plan Year If "Yes ", indicate number of days: Default Grace Period (Plan Extension): ❑ N/A ❑ No ❑ Yes ❑ No ❑Yes 75 days Run -Out Period: ❑ N/A ❑ No ❑ Yes ❑ No Yes 90 days NOTE: Grace and Run Out are consecutive, NOT concurrent. If you choose 75 days for the Grace and 90 days for the Run Out, your plan will extend a total of 165 days. TC- 3923 - 080111 Employer Initial , f`TASC 1 6