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) Plan Start <br /> • Check if Mid Plan Year takeover — If elected, please indicate the current Plan Year dates under the current third party <br /> administrator. From: / / (mo /dd /yr) To: / / (mo /dd /yr) <br /> TASC 'rst year administration shall begin on the first day of / (mo /yr) and continue for consecutive months. <br /> For the -cond and successive years, the Plan shall operate starting on the first day of / (month /year) and continue <br /> for the fo 'wing successive twelve (12) month period. Note: Plans need not run on the calendar year (i.e. January 1 - December 31). <br /> Are you choos g a short Plan Year (less than 12 months)? ❑ Yes ❑ No <br /> If yes, do you wis ' to extend a deductible credit to your Participants based on the amount of the health insurance deductible <br /> that has been satis -d thus far within this Plan Year? ❑ Yes ❑ No If yes, please submit credit amounts. <br /> (D) Plan Funding (Require. or full administration Plans) <br /> To fund your account, Direct •y (TASC) will initiate debit entries from the checking account and financial institution named below: <br /> 11 l - i <br /> - -J _1_ 1 - -; <br /> Bank Routing Number Checking Account Number <br /> DirectPay Admin. Only - Special Instru ns <br /> Funding: % (Minimum of 25 %) <br /> (8) COBRATODAY <br /> Total number of employees . Total numb: of employees on employer's health insurance plan <br /> Current COBRA administrator: ❑ Self ❑ Other Current number of participants in COBRA* <br /> (A) Subsidiaries, Affiliates or Divisions <br /> Identify all subsidiaries, affiliates, or divisions to be included under thi . rogram and identify whether they are to be established as a separate <br /> group for service communications. <br /> Set -up 5 • aratelv <br /> 1. Yes ❑ ❑ <br /> 2. Yes ❑ No <br /> 3. Yes n No [7 <br /> (B) Health Carriers <br /> Identify all health carriers (including current health insurance plan, HMO, dental, vision, EA• MFSA, etc.). Please note if any Plan is <br /> self- insured: <br /> 1. 4. <br /> 2. 5. <br /> 3. 6. <br /> (C) Plan Start <br /> Applications must be received by the 15th of the month if they are to begin on the first day of the , Ilowing month. <br /> First year administration shall begin on the 1st day of month /year. <br /> (D) COBRA Period Begins: <br /> ❑ First of month, following qualifying event <br /> ❑ Day after qualifying event <br /> ❑ Other (please specify): <br /> *Premium Collection Form is required at time of Plan Application along with Takeover Qualified Beneficiary Form(s). <br /> COBRAToday Admin. Only - Special Instructions <br /> TC -3923- 080111 Employer Initial I ,'LTASC <br /> 20 <br />