Plan Application

Company Name(Required)

EIN Number

Federal Filing Status

Multi-Employer Group (Check All That Apply)

PEO

ASO

MEWA

Joint Employer

Integrated Employer

Controlled Group

Governmental Entity

Municipality

Total Number of Employees

Total Number of Benefit Eligible Employees (Medical/Dental/Vision)

Total Number of Employees Participating in Group Benefit Plans (Medical/Dental/Vision)

Estimated Number of Universal Benefit Account Participants

Nature of Business

NAICS Code

Primary/Physical Address of Company (No P.O. Box)

Billing Address (If Different Than Primary Address)

Mailing/Shipping Address (If Different Than Primary Address)

Name of Client Primary Contact(Required)

Email Address(Required)

Phone Number(Required)

Name of Client/Plan Implementation Contact

Email Address

Phone Number

Name of Billing Contact

Email Address

Phone

Name of Distributor/Broker

Email Address

Phone

List all Types of TASC Services and Associated Fees(Required)

Additional Comments or Special Instructions

Submitted By(Required)

First Last

Partner Name(Required)