2012-09-26 CC Packet - Laserfiche WebLink

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(E) Plan Funding (Required) The funding of your Participants' Flexible Spending Accounts will be set -up according to your payroll schedule. The Expected Date of Receipt (EDR) is the date TASC will expect to receive your funding payment. You may set your EDR to be the same day as your payroll or up to three days following payroll. The default method for making the contributions is TASC Auto ACH (on the EDR on your behalf, TASC initiates submission of your funding via ACH). Select from below to initiate the fulfillment of this requirement. To start this process, (1) choose which ACH process you want, (2) select your EDR, and (3) provide your bank information. (1) TASC Auto ACH (TASC initiates TASC's funding payment via ACH on the EDR.) This is the default selection. ❑ Client initiates funding payment via MyTASC on or before the EDR. Note: Under this option, TASC will use your Account and Routing Numbers to post any unpaid funding amounts that are one (1) business day past the EDR. Note: Additional annual fee will apply if ACH is not elected ($10 per payroll). (2) Please indicate the number of business days TASC will receive your funding payment: Same Day as payroll (default) ❑ 1 Day after payroll ❑ 2 Days after payroll ❑ 3 Days after payroll (3) Bank Routing Number Checking Account Number 1 i (F) TASC Card Feature For auto - substantiation, enter all applicable co -pay amounts: ❑ Medical /Office $ ❑ Prescription Drug $ ❑ Opt Out of TASC Card (additional fees apply) FlexSystem Admin. Only - Special Instructions (6) TASC HSA (HEALTH SAVINGS ACCOUNT) TASC HSA Plan Selection: ❑ TASC HSA Full Service* ❑ HSA Limited* ❑ HSA Plan Only HSA Plan Start Date: Number of RSA Eligible Employees: Is this an existing HSA? ❑ Yes ❑ No Number of Payroll Contributions: Date of Employee's first payroll contribution: Frequency of Employee Contributions: ❑ Weekly ❑ Bi- Weekly ❑ Monthly ❑Other (please explain) Employer Contributions: ❑ Yes ❑ No Amount of Employer Contribution: $ Is the Employer Contribution set up based on individual HSA or Family HSA? ❑ Individual ❑ Family ❑ Both Is this a one time Employer Contribution? ❑ Yes ❑ No If yes, please provide date of one time contribution: If no, the Employer Contributions will be made: ❑ Annually ❑ Quarterly ❑ Monthly ❑ Each pay period *ADDITIONAL FORMS REQUIREMENT: The TASC HSA Payroll Schedule Request form for each payroll group and an HSA ACH Bank Withdrawal Authorization form, and must be submitted with all full service TASC HSA applications. ❑ I understand the pay dates can NOT be changed once the plan is enrolled. ❑ I understand TASC will send an e-mail prior to withdrawing funds for my account and that I should contact TASC with any changes no later than three 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 full administrative 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 client acknowledges they have amended their Section 125 Plan to include the required HSA language to allow HSA contributions to be pre -taxed and their Section 125 Plan Documents and SPD's are current according to Federal Law. TC -3923- 080111 Employer Initial Mk. TASC' 18