NCS Form 20 - 5G Government Benefits Collection Form

National Compensation Survey

NCS Form 20-5G (2020) - 2020NCS Benefits GOVc

National Compensation Survey (State and local government sample)

OMB: 1220-0164

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U.S. Department of Labor

Bureau of Labor Statistics




National Compensation Survey




The BLS publishes statistical tabulations from this survey that may reveal the information reported by individual State and local governments.  Upon your request, however, the BLS will hold the information provided on this survey form in confidence.




This report is authorized by law, 29 U.S.C. 2. Your voluntary cooperation is needed to make the results of this survey comprehensive, accurate and timely.



O.M.B. #1220-0164

Expires XX/XX/XXXX

We estimate that it will take an average of 180 minutes to complete this form, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing this information. If you have any comments regarding this estimate or any other aspect of this survey, including suggestions for reducing this burden, please send them to the Bureau of Labor Statistics, Office of Compensation and Working Conditions (1220-0164), 2 Massachusetts Avenue N.E., Washington, D.C. 20212. You are not required to respond to the collection of information unless it displays a currently valid OMB control number.


BENEFITS COLLECTION FORM FOR GOVERNMENTS

Establishment: _______________________________________ Schedule #: ______________

EIN: _____________________ Field Economist: _____________ Date Collected: __________



Status


Est.

Quotes

All

1

2

3

4

5

6

7

8

Usable











On strike











Temporary non-response











Refusal (Explain)











No matching jobs











Explain: ________________________________________________________

_________________________________________________________________


Benefit

Estab.

Quotes (Indicate NP or RE)

NP*

RE*

1

2

3

4

5

6

7

8

Overtime (Premium pay)











Vacations











Holidays











Sick leave











Personal leave











Shift differentials











Non-production bonus











Life insurance











Health insurance











Short-term disability











Long-term disability











Defined benefit











Defined contribution











Social Security











Medicare











Federal Unemployment Tax Act











State unemployment











Workers compensation











*NP= no plan offered, *RE= unknown whether a plan exists


NCS Form 20-5G (2020)


Benefit Collection Address/Officials Sched. # _______________________


(Fill out this page if different Address/Official contacted from the Wage Address/Officials listed on the “General Establishment Information” section in IDC.)


Benefit Collection Address # 1.

Physical Address Personal Visit Address Mailing Address


Company Name:


Secondary Name (Doing Business As):


Address:


City/State/ZIP:



Authorizing Supplying

Name:


Telephone


Title:


Fax




Email Address


Benefits to be collected here are:

#’s___,___,___,___,___,___,___,___,___,___,___,___,___,___,___


Benefit Collection Address # 2.

Physical Address Personal Visit Address Mailing Address


Company Name:


Secondary Name (Doing Business As):


Address:


City/State/ZIP:



Authorizing Supplying

Name:


Telephone


Title:


Fax




Email Address


Benefits to be collected here are:

#’s___,___,___,___,___,___,___,___,___,___,___,___,___,___,___


Benefit Collection Address # 3.

Physical Address Personal Visit Address Mailing Address

Company Name:


Secondary Name (Doing Business As):


Address:


City/State/ZIP:



Authorizing Supplying

Name:


Telephone


Title:


Fax




Email Address


Benefits to be collected here are:

#’s___,___,___,___,___,___,___,___,___,___,___,___,___,___,___

ESTABLISHMENT Sched. # _______________________


Shape1

Company Provisions

HEALTH

Does the establishment offer health insurance benefits to any employees?

Yes

No

Not determinable


Did the establishment use a Small Business Health Option Program (SHOP) exchange marketplace for health Insurance plans?

Yes

No

Not determinable


DEFINED BENEFITS

If no plan is available for matched employees, are defined benefit plans offered to any employees?

Yes

No

Not determinable


DEFINED CONTRIBUTION

If no plan is available for matched employees, are defined contribution plans offered to any employees?

Yes

No

Not determinable

OVERTIME (PREMIUM PAY, Benefit 01) Sched. # _______________________

Quotes: ________________________ Date of expected change (DOEC): __________

Eligibility: _______________________ Plan name: _______________________


Shape2





Quote:

Type, Premium, and Annual Hours




Average Occupational

Employment

Daily after

___ hours

Weekly after

____ hours

Paid Holidays*

_____X –1 X


Weekends


Other (specify)

Premium: _________

Premium: _________

Premium: _________

Premium: _________

Premium: _________

Annual hours per quote

Annual hours per quote

Annual hours

per quote

Annual hours per quote

Annual hours per quote

1







2







3







4







5







6







7







8







*for paid holidays subtract out regular holiday pay


Remarks/Calculations:
















Shape3

Payment Basis: Time Basis:

Base pay (BP) Regular work schedule

AVERAGE HOURLY RATE (AHR) Alternate work schedule

AHR + Shift (SD) Other (specify): _____________

AHR + Bonus (BN)

Other (specify): _____________


Expenditure cost: $___________________________________ Expenditure:

# of employees: __________________________________ Calendar year _____________

GR or SE Payroll = $ _____________________ Fiscal year ending ____/______/_____

Annual overtime hours: ___________________________

VACATION (Benefit 02) Sched. # _______________________

Shape4


Plan # 1 name:________________________

LOS

Vacation Plan
Eligibility: __________________________



Quotes: ____________________________



Vacation schedule:



Percent of earnings



Union fund



Time



Is this part of a consolidated leave plan?



Yes No ND (NOT DETERMINABLE)



If yes, check all that apply:



Vacation Personal ND (NOT DETERMINABLE)



Military Sick



Holidays Family



Jury Duty Funeral




Plan # 2 name:_______________________

LOS

Vacation Plan
Eligibility: __________________________



Quotes: ____________________________



Vacation schedule:



Percent of earnings



Union fund



Time



Is this part of a consolidated leave plan?



Yes No ND (NOT DETERMINABLE)



If yes, check all that apply:



Vacation Personal ND (NOT DETERMINABLE)



Military Sick



Holidays Family



Jury Duty Funeral




Shape5

Payment Basis: Time Basis:

Base pay (BP) Regular work schedule

AVERAGE HOURLY RATE (AHR) Alternate work schedule

AHR + Shift (SD) Other (specify): _____________

AHR + Bonus (BN)

Other (specify): _____________


Expenditure cost: $___________________________________ Expenditure:

# of employees: __________________________________ Calendar year _____________

GR or SE Payroll = $ _____________________ Fiscal year ending ____/______/_____


VACATION (SUPPLEMENTARY SHEET) Sched. #_______________________

Date of expected change (DOEC): __________

Shape6



Schedule

Quotes

1

2

3

4

5

6

7

8

L.O.S.

D.O.H.









Less 1 month









1 month









2 months









3 months









4 months









5 months









6 months









7 months









8 months









9 months









10 months









11 months









1 year









2 years









3 years









4 years









5 years









6 years









7 years









8 years









9 years









10 years









11 years









12 years









13 years









14 years









15 years









16 years









17 years









18 years









19 years









20 years









21 years









22 years









23 years









24 years









25 years









26 years









27 years









28 years









29 years









30 years









30+ years









Occupational

Employment












HOLIDAYS (Benefit 03) Sched. #_______________________

Quotes: ________________________ Date of expected change (DOEC):___________

Eligibility: _______________________ Plan name: _______________________

Shape7



Holidays

Number of days


Holidays

Number of days

Paid

Unpaid

Paid

Unpaid

New Year’s Eve

.

.

Veteran’s Day

.

.

New Year’s Day

.

.

Thanksgiving Day

.

.

Shape8 Martin Luther King’s Birthday

.

.

Day after Thanksgiving

.

.

President’s Day

.

.

Christmas Eve

.

.

Good Friday

.

.

Christmas Day

.

.

Memorial Day

.

.

Employee’s Birthday

.

.

July 4th

.

.

Floating

.

.

Labor Day

.

.

Other (specify):

.

.

Columbus Day

.

.


Total days


.


.

Election Day

.

.


Remarks/Calculations:


















Shape9

Payment Basis: Time Basis:

Base pay (BP) Regular work schedule

AVERAGE HOURLY RATE (AHR) Alternate work schedule

AHR + Shift (SD) Other (specify): _____________

AHR + Bonus (BN)

Other (specify): _____________


Expenditure cost: $___________________________________ Expenditure:

# of employees: __________________________________ Calendar year _____________

GR or SE Payroll = $ _____________________ Fiscal year ending ____/______/_____

SICK LEAVE (Benefit 04) Sched. #_______________________

Quotes: ________________________ Date of expected change (DOEC): __________

Eligibility: _______________________ Plan name: _______________________

Shape10


Shape11

Sick leave plan:

___Days paid as needed

__ Max. days per year

__ Other (specify)

__ Not determinable

Schedule

Paid Days at 100%

Unpaid Days


























Waiting Period: Yes No Number of Days for waiting period ____________

Unlimited days: Yes No


Leave Usage (days) Worksheet:


Carry over: All Limited For Limited Maximum Days _____________

Informal plan: Yes No


Paid

Unpaid

Other

Remarks/Calculations:












Shape12

Payment Basis: Time Basis:

Base pay (BP) Regular work schedule

AVERAGE HOURLY RATE (AHR) Alternate work schedule

AHR + Shift (SD) Other (specify): _____________

AHR + Bonus (BN)

Other (specify): _____________


Expenditure cost: $___________________________________ Expenditure:

# of employees: __________________________________ Calendar year _____________

GR or SE Payroll = $ _____________________ Fiscal year ending _____/______/_____

PERSONAL LEAVE (Benefit 05) Sched. #_______________________

Date of expected change (DOEC): __________

Shape13

Leave Plan

Quotes Covered

Eligibility

Paid Days

Payment Rate

Unpaid Days

Personal Leave






Other (specify) Paid Leave






Leave Without Pay









Quote

Personal

Other

Occ. Employ.

Paid

Unpaid

Paid

Unpaid


1






2






3






4






5






6






7






8







Remarks/Calculations:








Shape14

Payment Basis: Time Basis:

Base pay (BP) Regular work schedule

AVERAGE HOURLY RATE (AHR) Alternate work schedule

AHR + Shift (SD) Other (specify): _____________

AHR + Bonus (BN)

Other (specify): _____________


Expenditure cost: $___________________________________ Expenditure:

# of employees: __________________________________ Calendar year _____________

GR or SE Payroll = $ _____________________ Fiscal year ending _____/______/_____



SHIFT DIFFERENTIAL (Benefit 06) Sched. #_______________________

Quotes: ________________________ Date of expected change (DOEC): __________

Eligibility: _______________________ Plan name: _______________________

Shape15



Quote

Total EE*

1st Shift EE*

2nd shift

3rd shift

Other: __________________

2nd

EE*


$*


%*

Hrs Pd

Hrs

Wk

3rd

EE


$


%

Hrs Pd

Hrs Wk

Other

EE


$*


%*

Hrs Pd*

Hrs Wk*

1


















2


















3


















4


















5


















6


















7


















8


















*Total EE= total employment of quote; *1st Shift EE= first shift employment; *$= cents or dollars per hour of differential; *%= percent extra paid for shift differential over straight time rate; *Hrs Pd= hours paid per shift; *Hrs Wk= hours worked per shift


Remarks/Calculations:














Shape16

Payment Basis: Time Basis:

Base pay (BP) Regular work schedule

AVERAGE HOURLY RATE (AHR) Alternate work schedule

AHR + Shift (SD) Other (specify): _____________

AHR + Bonus (BN)

Other (specify): _____________


Expenditure cost: $___________________________________ Expenditure:

# of employees: __________________________________ Calendar year _____________

GR or SE Payroll = $ _____________________ Fiscal year ending ____/______/_____



NONPRODUCTION BONUS (Benefit 07) Sched. #_______________________

Quotes: ________________________ Date of expected change (DOEC): __________

Eligibility: _______________________ Plan name: _______________________


Shape17


Plan Type

Provisions/Benefit Formula


Attendance



Cash profit sharing



Employee recognition program



End-of-year discretionary bonus



Hiring



In-lieu of benefit payment



Longevity bonus



Management incentive bonus



Safety



Signing



Suggestion



Union-related



Retention bonus



Referral bonus



Other (specify)



Not determinable



Usage/Cost:









Shape18

Payment Basis: Time Basis:

Base pay (BP) Regular work schedule

AVERAGE HOURLY RATE (AHR) Alternate work schedule

AHR + Shift (SD) Other (specify): _____________

AHR + Bonus (BN)

Other (specify): _____________


Expenditure cost: $___________________________________ Expenditure:

# of employees: __________________________________ Calendar year _____________

GR or SE Payroll = $ _____________________ Fiscal year ending ____/______/_____



LIFE INSURANCE (Benefit 10) Sched. #_______________________

Quotes: ________________________ Date of expected change (DOEC): __________

Eligibility: _______________________ Plan name: _______________________

Shape19


Plan No.

Name

Type

01



02



03




Remarks/Calculations:























Shape20

Payment Basis: Time Basis:

Base pay (BP) Regular work schedule

AVERAGE HOURLY RATE (AHR) Alternate work schedule

AHR + Shift (SD) Other (specify): _____________

AHR + Bonus (BN)

Other (specify): _____________


Expenditure cost: $___________________________________ Expenditure:

# of employees: __________________________________ Calendar year _____________

GR or SE Payroll = $ _____________________ Fiscal year ending ____/______/_____


LIFE INSURANCE (Benefit 10) Sched. #_______________________

Shape21


Type:


Plan no.

Eligibility

01


02


03



Formula: (Choose one formula and answer columns accordingly.)


Plan no.

Multiple of earnings

Max. benefit amount.

Enter $, No, or ND*

Flat Amount


Other

()


ND*

()

Varies ()

Fixed (Enter multiple)

Varies ()

Fixed

(Enter $)

01








02








03








*ND= Not determinable

Financing: (Choose one financing type and answer columns accordingly.)




Plan no.

Commercially Insured


Self-insured ()

Union Health/Welfare

Enter: Carrier

Enter: Plan Year

Date of expected change (DOEC)

01





02





03






Premiums: (Enter $ amount, No cost, Not determinable)


Plan no.

Company (ER) Cost

Employee (EE) Cost

Total Cost

Earnings Ceiling

01





02





03






Participation (Needed if collection by Rate and Usage)


Plan no.

Quotes

1R

1P

2R

2P

3R

3P

4R

4P

5R

5P

6R

6P

7R

7P

8R

8P

01

















02

















03

















R= Participation (# employees in quote taking plan); P= potential participants (total # employees in quote)


Shape22

HEALTH INSURANCE (Benefit 11) Sched. #_______________________

Shape23

Type:



Plan No.


Plan Name/

Carrier


Elig

Type of (2)

Coverage ()

Pay after services rendered

(3)

Outside network higher cost (3b)

Does Employer pay any portion of claims

(4)

M

D

V

P

01










02










03










04










05










06










07










08










09










10










M= Medical; D= Dental; V= Vision; P= Prescription drugs

  1. Does this plan pay benefits after services are rendered, typically after coinsurance and deductibles?

3b. Can the enrollee go outside the network of plan providers for coverage at higher cost?

  1. Does the employer pay any portion of claims?


Basic Information:



Plan No.

EIN (Employer Identification #)

PN (Plan #)

SPD*(Y/N)

SPD* Date

Master Schedule

01






02






03






04






05






06






07






08






09






10






*SPD= Summary Plan Description are required at initiation for all health plans.


HEALTH INSURANCE (Benefit 11) Sched. # _______________________

Shape24


Financing: (Choose one financing type and answer columns accordingly.)




Plan no.


Commercially Insured


Self-insured

() answer 1. and 2.

1. Use of third-party administrators (Y/N)

Union Health/Welfare (Enter date)

2. Use of insurance for claims that exceed certain limits

(stop-loss)


Carrier

Plan Year

Expected change

01







02







03







04







05







06







07







08







09







10








Cost: Plan No. _____ (Enter $ amount, No cost, Not determinable)


Premiums

Company (ER) Cost

Employee (EE) Cost

Conversion Code

Total Cost

Single





Family





EMP. + Spouse





EMP. + Child





EMP. + 1





EMP. + 2





EMP. + 3





EMP. + 4





OTHER:_______






Participation: Plan No. _____ (Enter % of quote employment, Not determinable, Not applicable)




Quotes

1

2

3

4

5

6

7

8

Single









Family









EMP. + Spouse









EMP. + Child









EMP. + 1









EMP. + 2









EMP. + 3









EMP. + 4









Total participation











HEALTH INSURANCE (Benefit 11) Sched. # _______________________

Quotes: ________________________ Date of expected change (DOEC): __________

Eligibility: _______________________ Plan name: _______________________

Shape25



































Shape26

Payment Basis: Time Basis:

Base pay (BP) Regular work schedule

AVERAGE HOURLY RATE (AHR) Alternate work schedule

AHR + Shift (SD) Other (specify): _____________

AHR + Bonus (BN)

Other (specify): _____________


Expenditure cost: $___________________________________ Expenditure:

# of employees: __________________________________ Calendar year _____________

GR or SE Payroll = $ _____________________ Fiscal year ending ____/______/_____


SHORT-TERM DISABILITY (Benefit 12) Sched. # _______________________

Shape27

3. Waiting Period: Yes No Number of Days of waiting period ____________

Duration: Fixed # weeks ________ Number of weeks varies ND



1. Financing: (Choose one financing type and answer columns accordingly.)




Plan no.

Commercially Insured


Self-insured ()

Union Health/Welfare

Date of expected change (DOEC)

Unfunded

(Write details in remarks)

State

()

Other

()

ND*

()

Enter: Carrier

Enter: Plan Year

01









02









03









*ND= not determinable


2. Formula: (Choose one formula and answer columns accordingly.)




Plan no.

Percent of earnings ()

Max. benefit per week.

Enter $, No, or ND*

Flat Amount


Other

()


ND*

()

Varies ()

Fixed (Enter %)

Varies ()

Fixed

(Enter $)

01








02








03








*ND= not determinable


Premiums: (Enter $ amount, No cost, Not determinable)


Plan no.

Company (ER) Cost

Employee (EE) Cost

Total Cost

Earnings Ceiling

01





02





03






Participation: (Enter % of quote employment, Not determinable, Not applicable)



Plan no.

Quotes

ALL

1

2

3

4

5

6

7

8

01










02










03












SHORT-TERM DISABILITY (Benefit 12) Sched. # _______________________

Quotes: ________________________ Date of expected change (DOEC): __________

Eligibility: _______________________ Plan name: _______________________

Shape28


Remarks/Calculations:





























Shape29

Payment Basis: Time Basis:

Base pay (BP) Regular work schedule

AVERAGE HOURLY RATE (AHR) Alternate work schedule

AHR + Shift (SD) Other (specify): _____________

AHR + Bonus (BN)

Other (specify): _____________


Expenditure cost: $___________________________________ Expenditure:

# of employees: __________________________________ Calendar year _____________

GR or SE Payroll = $ _____________________ Fiscal year ending _____/______/_____


LONG-TERM DISABILITY (Benefit 23) Sched. # _______________________

Shape30

Waiting Period: Yes No Number of Days ____________


1. Formula:



Plan no.

Percent of earnings ()

If fixed, enter # or ND*

Max. benefit amount. Enter $, No, or ND

Flat Amount ()


Other

()


ND*

()

Varies

Fixed

01








02








03








*ND= not determinable


Financing: (Choose one financing type and answer columns accordingly.)



Plan no.

Commercially Insured

Self-insured ()

Union Health/Welfare

Enter: Carrier

Enter: Plan Year

Date of expected change (DOEC)

01





02





03






Premiums: (Enter $ amount, No cost, Not determinable)


Plan no.

Company (ER) Cost

Employee (EE) Cost

Total Cost

Earnings Ceiling

01





02





03






Participation: (Enter % of quote employment, Not determinable, Not applicable)



Plan no.

Quotes

ALL

1

2

3

4

5

6

7

8

01










02










03












LONG-TERM DISABILITY (Benefit 23) Sched. # _______________________

Quotes: ________________________ Date of expected change (DOEC): __________

Eligibility: _______________________ Plan name: _______________________


Shape31


Remarks/Calculations:






























Shape32

Payment Basis: Time Basis:

Base pay (BP) Regular work schedule

AVERAGE HOURLY RATE (AHR) Alternate work schedule

AHR + Shift (SD) Other (specify): _____________

AHR + Bonus (BN)

Other (specify): _____________


Expenditure cost: $___________________________________ Expenditure:

# of employees: __________________________________ Calendar year _____________

GR or SE Payroll = $ _____________________ Fiscal year ending ____/______/_____



DEFINED BENEFIT PLANS (Benefit 13) Sched. ________

Shape33

1.Basic Information:


Plan No.

Plan Name/Carrier

Eligibility

EIN (Employer identification #)

PN (Plan #)

SPD*

(Y/N)

SPD* Date

Master Schedule

01








02








03








*SPD= Summary Plan Description are required at initiation for all defined benefit plans.


2.Provisions:


Employee required contributions



Plan no.


None

()

Percent of earnings

Coordinated with Social Security ()

Other

()

ND*

()

COLA*

()

Enter %

% ND*

01








02








03








COLA= Cost of living adjustment; *ND= not determinable


3. Are new employees able to participate in the DB plan? Yes No ND

4. In what year did new employees become ineligible for the DB plan _____

5. For this plan have benefits been frozen, or are they still accruing for participants?

All current Subset of current No current participants are accruing benefits ND

6. What are other retirement plan options for new employees who cannot participate in this plan?

New DB plan New DC plan Enhancement of existing DC plan Other None ND


Financing: (Not necessary to code)


Plan no.

Commercially Insured

Union Fund

Enter: Carrier

Enter: Plan Year

Date of expected change (DOEC)

01




02




03





Premiums: (Enter $ amount, No cost, Not determinable)


Plan no.

Company (ER) Cost

Employee (EE) Cost

Total Cost

01




02




03






Participation: (Enter % of quote employment, Not determinable, Not applicable)


Plan no.

Quotes

ALL

1

2

3

4

5

6

7

8

01










02










03











DEFINED BENEFIT (Benefit 13) Sched. # _______________________

Quotes: ________________________ Date of expected change (DOEC): __________

Eligibility: _______________________ Plan name: _______________________

Shape34


Remarks/Calculations:






















Shape35

Payment Basis: Time Basis:

Base pay (BP) Regular work schedule

AVERAGE HOURLY RATE (AHR) Alternate work schedule

AHR + Shift (SD) Other (specify): _____________

AHR + Bonus (BN)

Other (specify): _____________


Expenditure cost: $___________________________________ Expenditure:

# of employees: __________________________________ Calendar year _____________

GR or SE Payroll = $ _____________________ Fiscal year ending ____/______/_____


PBGC

Annual per employee cost: _____________ Annual Expenditure: __________________


DEFINED CONTRIBUTION (Benefit 14), UNDUPLICATED TOTALS Sched. #_________

Shape36

1. Provisions:


Plan no.

Type*

Required Employee contribution ()

Contributions tax-deferred?

01




02




03




04




* Deferred Profit Sharing, ESOP, Money Purchase Plan, Savings & Thrift, SEP, SIMPLE, Stock bonus, Other (specify), or Not Determinable


2. Basic Information:


Plan No.

Plan Name/Carrier

Eligibility

EIN (Employer identification #)

PN (Plan #)

SPD*

(Y/N)

SPD* Date

Master Schedule

01








02








03








04








*SPD= Summary Plan Description are required at initiation for all defined contribution plans.


3. Must the employee contribute to receive the employer contribution? Yes No ND


4. Are any employee contributions tax deferred? Yes No ND


Participation: (Enter % of quote employment, Not determinable, Not applicable)


Plan no.

Quotes

ALL

1

2

3

4

5

6

7

8

01










02










03










04











Unduplicated Totals:

Collect the percentage of employment in DC-only, DB-only, and both DC and DB data, if both the DB and DC plan participation, is between 0 and 100 percent. If the plan participation in either benefit is 0 or 100 percent, the system will compute the unduplicated totals.


Quote

Retirement Percentages

% DefinedContribution Only (DC-only)

% Defined Benefit Only (DB-only)

% Both DC and DB

1




2




3




4




5




6




7




8




DEFINED CONTRIBUTION (Benefit 14), UNDUPLICATED TOTALS

Sched. # _______________________

Quotes: ________________________ Date of expected change (DOEC): __________

Eligibility: _______________________ Plan name: _______________________

Shape37


Remarks/Calculations:

































Shape38

Payment Basis: Time Basis:

Base pay (BP) Regular work schedule

AVERAGE HOURLY RATE (AHR) Alternate work schedule

AHR + Shift (SD) Other (specify): _____________

AHR + Bonus (BN)

Other (specify): _____________


Expenditure cost: $___________________________________ Expenditure:

# of employees: __________________________________ Calendar year _____________

GR or SE Payroll = $ _____________________ Fiscal year ending _____/______/_____

SOCIAL SECURITY, MEDICARE, FUTA (Benefit 15, 16, 19) Sched. # _______________________

Date of expected change (DOEC): __________

Shape39

Are all employees covered by:


Social Security: Yes No

Medicare: Yes No

FUTA: Yes No



Participation: (Enter % of quote employment, Not determinable, Not applicable)


Benefit

Quotes

All

1

2

3

4

5

6

7

8

Social Security










Medicare










FUTA












Does employer report tips for any sampled occupation? Yes (Answer table) No


Quote:

All

1

2

3

4

5

6

7

8

Average Hourly Rate










Average Tips Per Hour










Total Employees











Remarks/Calculations:

















STATE UNEMPLOYMENT INSURANCE, WORKERS’ COMPENSATION (Benefits 20, 21)

Sched. # _______________________

Shape40

STATE UNEMPLOYMENT INSURANCE

Quotes: ________________________ Date of expected change (DOEC): ___________

Eligibility: _______________________ Plan name: ________________________


Financing:


State Insured (Enter rate and add-on data below if different from State)

Rate _____________%

Add-on rate(s), if any ________________%

Self-Insured/Reimbursement

Railroad plan

Nonprofit plan


Does employer report tips for any sampled occupation? Yes (Answer table) No

Quote:

ALL

1

2

3

4

5

6

7

8

Average Hourly Rate










Average Tips Per Hour










Total Employees











Expenditure cost: $___________________________________ Expenditure:

# of employees: __________________________________ Calendar year _____________

GR or SE Payroll = $ _____________________ Fiscal year ending ____/_____/____


Shape41

WORKERS’ COMPENSATION

Quotes: ________________________ Date of expected change (DOEC): ___________

Eligibility: _______________________ Plan name: ________________________


Financing:


Self-Insured Commercially Insured (Answer grid)


QUOTE

W.C. Code

Rate

Experience Modifier

Premium Discount

1





2





3





4





5





6





7





8






Expenditure cost: $___________________________________ Expenditure:

# of employees: __________________________________ Calendar year _____________

GR or SE Payroll = $ _____________________ Fiscal year ending ____/_____/____


Other Benefits Sched. # _______________________

Date of expected change (DOEC): ___________

Eligibility: _______________________ Plan name: ________________________

Shape42


Benefit

Access for each benefit

Quotes

ND*

All

None

1

2

3

4

5

6

7

8

Paid Personal Leave












Paid Funeral Leave












Paid Military Leave












Paid Jury Duty












Paid Family Leave












Unpaid Family Leave












Child Care Assistance












Flexible Workplace












Flexible Work Schedule












Subsidized Commuting












Wellness Programs












Employee Assistance Program












Health Savings Accounts (HSA)












Flexible Benefits












Health Flexible Spending Account












Dependent Care Flex Spending Acct












Cash Defer’d Arrangement, no ER contribution












Payroll Deduction IRA












Financial Planning












Student Loan Repayment












Long-term Care Insurance












Retiree Health – under age 65












Retiree Health – age 65 and over
























Does your establishment offer health benefits to unmarried domestic partners

1. Of the opposite sex?












2. Of the same sex?












As part of a defined benefit plan, does your establishment offer survivor benefits to unmarried domestic partners

1. Of the opposite sex?












2. Of the same sex?












*ND = Not determinable









Sched. # _______________________


Cost Grids

Overtime


Quote

Status Code

Value Entry

Conversion Code

Annual Overtime Hours

Average Premium

AWS*

ALL







1







2







3







4







5







6







7







8







*AWS= Alternate Work Schedule

Vacation


Quote

Status Code

Value Entry

Conversion Code

Paid Weeks

Unpaid Weeks

AWS*

ALL







1







2







3







4







5







6







7







8







*AWS= Alternate Work Schedule


Holiday


Quote

Status Code

Value Entry

Conversion Code

Paid Days

Unpaid Days

AWS*

ALL







1







2







3







4







5







6







7







8







*AWS= Alternate Work Schedule



Sched. # _______________________


Sick Leave


Quote

Status Code

Value Entry

Conversion Code

Paid Days

Unpaid Days

AWS*

ALL







1







2







3







4







5







6







7







8







*AWS= Alternate Work Schedule

Personal Leave


Quote

Status Code

Value Entry

Conversion Code

Paid Days

Unpaid Days

AWS*

ALL







1







2







3







4







5







6







7







8







*AWS= Alternate Work Schedule

Nonproduction Bonus


Quote

Status Code

Value Entry

Conversion Code

Paid Days

AWS*

ALL






1






2






3






4






5






6






7






8






*AWS= Alternate Work Schedule


Sched. # _______________________




Life Insurance


Quote

Status Code

Value Entry

Multi Earnings Cov.

Flat Amount Cov.

Conversion Code

Ceiling

AWS*

ALL








1








2








3








4








5








6








7








8








*AWS= Alternate Work Schedule


Health Insurance


Quote

Status Code

Value Entry

Conversion Code

AWS*

ALL





1





2





3





4





5





6





7





8





*AWS= Alternate Work Schedule


Short-term Disability


Quote

Status Code

Value Entry

Conversion Code

Ceiling

AWS*

ALL






1






2






3






4






5






6






7






8






*AWS= Alternate Work Schedule

Sched. # _______________________


Long-term Disability


Quote

Status Code

Value Entry

Conversion Code

Ceiling

AWS*

ALL






1






2






3






4






5






6






7






8






*AWS= Alternate Work Schedule

Defined Contribution


Quote

Status Code

Value Entry

Conversion Code

Ceiling

AWS*

ALL






1






2






3






4






5






6






7






8






*AWS= Alternate Work Schedule

Defined Benefit


Quote

Status Code

Value Entry

Conversion Code

Ceiling

AWS*

ALL






1






2






3






4






5






6






7






8






*AWS= Alternate Work Schedule

Sched. # _______________________


Social Security


Quote

Status Code

Legally Required Factor

Value Entry

Conversion Code

AWS*

ALL






1






2






3






4






5






6






7






8






*AWS= Alternate Work Schedule

Medicare


Quote

Status Code

Legally Required Factor

Value Entry

Conversion Code

AWS*

ALL






1






2






3






4






5






6






7






8






*AWS= Alternate Work Schedule

FUTA


Quote

Status Code

Legally Required Factor

Value Entry

Conversion Code

AWS*

ALL






1






2






3






4






5






6






7






8






*AWS= Alternate Work Schedule

Sched. # _______________________


State Unemployment Insurance


Quote

Status Code

Value Entry

Conversion Code

Ceiling

AWS*

ALL






1






2






3






4






5






6






7






8






*AWS= Alternate Work Schedule


Workers’ Compensation


Quote

Status Code

Value Entry

Conversion Code

Ceiling

Rate

Exp.

Mod

Prem. Disc

AWS*

ALL








1









2









3









4









5









6









7









8









*AWS= Alternate Work Schedule

Sched. # _______________________


Additional tables for health insurance cost and plan participation

Cost: Plan No. _____ (Enter $ amount, No cost, Not determinable)

Premiums

Company (ER) Cost

Employee (EE) Cost


Conversion Code

Total Cost

Single





Family





EMP. + Spouse





EMP. + Child





EMP. + 1





EMP. + 2





EMP. + 3





EMP. + 4





OTHER:_______






Participation: Plan No. _____ (Enter % of quote employment, Not determinable, Not applicable)



Quotes

1

2

3

4

5

6

7

8

Single









Family









EMP. + Spouse









EMP. + Child









EMP. + 1









EMP. + 2









EMP. + 3









EMP. + 4









Total part.










Cost: Plan No. _____ (Enter $ amount, No cost, Not determinable)

Premiums

Company (ER) Cost

Employee (EE) Cost


Conversion Code

Total Cost

Single





Family





EMP. + Spouse





EMP. + Child





EMP. + 1





EMP. + 2





EMP. + 3





EMP. + 4





OTHER:_______






Participation: Plan No. _____ (Enter % of quote employment, Not determinable, Not applicable)



Quotes

1

2

3

4

5

6

7

8

Single









Family









EMP. + Spouse









EMP. + Child









EMP. + 1









EMP. + 2









EMP. + 3









EMP. + 4









Total part.









Sched. # _______________________

Cost: Plan No. _____ (Enter $ amount, No cost, Not determinable)

Premiums

Company (ER) Cost

Employee (EE) Cost


Conversion Code

Total Cost

Single





Family





EMP. + Spouse





EMP. + Child





EMP. + 1





EMP. + 2





EMP. + 3





EMP. + 4





OTHER:_______






Participation: Plan No. _____ (Enter % of quote employment, Not determinable, Not applicable)



Quotes

1

2

3

4

5

6

7

8

Single









Family









EMP. + Spouse









EMP. + Child









EMP. + 1









EMP. + 2









EMP. + 3









EMP. + 4









Total part.










Cost: Plan No. _____ (Enter $ amount, No cost, Not determinable)

Premiums

Company (ER) Cost

Employee (EE) Cost


Conversion Code

Total Cost

Single





Family





EMP. + Spouse





EMP. + Child





EMP. + 1





EMP. + 2





EMP. + 3





EMP. + 4





OTHER:_______






Participation: Plan No. _____ (Enter % of quote employment, Not determinable, Not applicable)



Quotes

1

2

3

4

5

6

7

8

Single









Family









EMP. + Spouse









EMP. + Child









EMP. + 1









EMP. + 2









EMP. + 3









EMP. + 4









Total part.










Sched. # _______________________

Cost: Plan No. _____ (Enter $ amount, No cost, Not determinable)

Premiums

Company (ER) Cost

Employee (EE) Cost


Conversion Code

Total Cost

Single





Family





EMP. + Spouse





EMP. + Child





EMP. + 1





EMP. + 2





EMP. + 3





EMP. + 4





OTHER:_______






Participation: Plan No. _____ (Enter % of quote employment, Not determinable, Not applicable)



Quotes

1

2

3

4

5

6

7

8

Single









Family









EMP. + Spouse









EMP. + Child









EMP. + 1









EMP. + 2









EMP. + 3









EMP. + 4









Total part.










Cost: Plan No. _____ (Enter $ amount, No cost, Not determinable)

Premiums

Company (ER) Cost

Employee (EE) Cost


Conversion Code

Total Cost

Single





Family





EMP. + Spouse





EMP. + Child





EMP. + 1





EMP. + 2





EMP. + 3





EMP. + 4





OTHER:_______






Participation: Plan No. _____ (Enter % of quote employment, Not determinable, Not applicable)



Quotes

1

2

3

4

5

6

7

8

Single









Family









EMP. + Spouse









EMP. + Child









EMP. + 1









EMP. + 2









EMP. + 3









EMP. + 4









Total part.










1

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleDraft of 2/23
AuthorPaul Carney
File Modified0000-00-00
File Created2021-03-06

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