SO100BF-1GP NCS Fillable Benefits Form

National Compensation Survey

NCS Form SO100BF-1GP Final

OMB: 1220-0164

Document [pdf]
Download: pdf | pdf
Bureau of Labor Statistics
Month Year Update

U.S. Department of Labor

OMB No.
Expiration Date:

1220-0164
X/XX/XXXX

We estimate that it will take an average of 20 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.

The Bureau of Labor Statistics, its employees, agents, and partner statistical agencies, will use the information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. In
accordance with the Confidential Information Protection and Statistical Efficiency Act (44 U.S.C. Section 3572) and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent
except in the case of state and local governments. The BLS publishes statistical tabulations from this report that may reveal the information reported by state and local governments. Upon request, however, the BLS will hold the
information provided by state and local governments on this report in confidence. Per the Federal Cybersecurity Enhancement Act of 2015, Federal information systems are protected from malicious activities through cybersecurity
screening of transmitted data. 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.

Benefits for:

Company Name and Physical Address

Links to Benefit Information Used:
Link to Respondent-Provided Benefit Information Website

Please update links when updates occur.

Link to Respondent-Provided Benefit Information Website
Link to Respondent-Provided Benefit Information Website
Link to Respondent-Provided Benefit Information Website
Hello [Respondent]
Please review the data below and update benefit information for: [Month Year]
If you have any questions, please contact me at: [BLS Field Economist Name, Email Address, and Telephone Number]
We are collecting benefit information on the following occupations:
Selected Job

Benefits Reported:

NCS : SO100BF-1GP

FT/PT

Wage Type

FLSA

Union Status

Hrs/Dy

Hrs/Wk

Wks/Yr

OVERTIME PREMIUM PAY

Last Date Reported:

Fill in Date

Date to Review Provisions:

Fill in Date

(Y/N) Have there been any changes to this policy since data was previously reported?
Please use the Current Update fields below to refresh previously reported data or to provide missing data.
Please provide estimated overtime usage for the OT eligible occupations below.
If there is additional data to report, please indicate in the Additional Comments field.
Previously Reported Data
Premium: Reporting Example: Premium Paid per OT Event (1.5x weekly after 40 hours)
Need Data Daily After:
Need Data Hours
Need Data Weekly After:

Need Data Hours

Current Update
Reporting Example: (Premium Paid per OT Event )

Daily After:

Hours

Weekly After:

Hours

Need Data Weekends:

Weekends:

Need Data Holidays:

Holidays:

Need Data Other:

Other:

Estimated Annual Overtime Usage per Occupation (Hours)

Est. Annual Usage per Occupation for 2020

Full-Time

Occupation Number 1

Need Data

Full-Time

Occupation Number 2

Need Data

Full-Time

Occupation Number 3

Need Data

Full-Time

Occupation Number 4

Need Data

Full-Time

Occupation Number 5

Need Data

Full-Time

Occupation Number 6

Need Data

Full-Time

Occupation Number 7

Need Data

Full-Time

Occupation Number 8

Need Data

Additional Comments:

LEAVE BENEFITS:

VACATION

Last Date Reported:

Fill in Date

Date to Review Provisions:

Fill in Date

(Y/N) Have there been any changes to this policy since data was previously reported?
Please use the Current Update fields below to refresh previously reported data or to provide missing data.
If there is additional data to report, please indicate in the Additional Comments field.
Vacation Plan for Full-Time
Previously Reported Data

Current Update

Employees Eligible for Paid Vacation Leave:

Need Data

Days Until Eligible for Paid Vacation Leave:

Need Data

Is this a Consolidated Leave Plan?

Need Data

If yes, what leave is included?
Accrual Per Pay Period : Reporting Example: (Hrs. Earned per Required Time Employed)
Vacation Hours Earned
Required Time Employed

Need Data

Need Data

Hours

Year(s)

Need Data

Need Data

Hours

Year(s)

Need Data

Need Data

Hours

Year(s)

Pay Is Based On: (Base Pay, Avg Hrly Rate, Avg Hrly Rate+Shift):
Additional Comments:

Reporting Example: (Hrs. Earned per Required Time Employed)

Need Data

LEAVE BENEFITS: HOLIDAYS

Last Date Reported:

Fill in Date

Date Expected to Change:

Fill in Date

(Y/N) Have there been any changes to this policy since data was previously reported?
Please use the Current Update fields below to refresh previously reported data or to provide missing data.
If there is additional data to report, please indicate in the Additional Comments field.
Previously Reported Data

Current Update

Employees Eligible for Paid Holiday Leave

Need Data

Days Until Eligible for Holiday Leave:

Need Data

Is the Workplace Open on Holidays?

Need Data

Estimate percent of employees working holidays:

Need Data

Are Employees Paid Holiday Overtime if they work?

Need Data

If Yes, What is The Overtime Rate?
If no, pay Is Based On:(Base Pay, Avg Hrly Rate, Avg Hrly Rate+Shift):

Need Data

Number of Paid Holidays:

Need Data
New Year's Eve
New Year's Day
Martin Luther King Day
President's Day
Good Friday
Memorial Day
July 4th
Labor Day
Columbus Day
Election Day
Veteran's Day
Thanksgiving Day
Day after Thanksgiving
Christmas Eve
Christmas Day
Employee Birthday
Floating Holiday
Other

If Other, please list:
Additional Comments:

Need Data

Need Data
Need Data
Need Data
Need Data
Need Data
Need Data
Need Data
Need Data
Need Data
Need Data
Need Data
Need Data
Need Data
Need Data
Need Data
Need Data
Need Data
Need Data

LEAVE BENEFITS: SICK LEAVE

Last Date Reported:

Fill in Date

Date to Review Provisions:

Fill in Date

(Y/N) Have there been any changes to this policy since data was previously reported?
Please use the Current Update fields below to refresh previously reported data or to provide missing data.
If there is additional data to report, please indicate in the Additional Comments field.
Previously Reported Data

Current Update

Employees Eligible for Unpaid Sick Leave

Need Data

Employees Eligible for Paid Sick Leave

Need Data

Days Until Eligible for Paid Sick Leave:

Need Data

Maximum Days of Paid Sick Leave Per Year:

Need Data

Accrual Policy:
Reporting Example: (Hrs. Earned per Required Time Worked)
Sick Leave Hours Earned
Required Work Time
Need Data
per
Need Data Hrs Worked
Pay Is Based On: (Base Pay, Avg Hrly Rate, Avg Hrly Rate+Shift):

Need Data

Is this a consolidated Leave Plan?

Need Data

If yes, what leave is included?

Need Data

Unused Sick Leave: (Cash In or Carry Over)

Need Data

If Carry Over, how much?

Need Data

Estimated Annual Sick Leave Usage per Occupation (Hours)

Hrs Per

Hrs Worked

Est. Annual Usage per Occupation for 2020

Full-Time

Occupation Number 1

Need Data

Full-Time

Occupation Number 2

Need Data

Full-Time

Occupation Number 3

Need Data

Full-Time

Occupation Number 4

Need Data

Full-Time

Occupation Number 5

Need Data

Full-Time

Occupation Number 6

Need Data

Full-Time

Occupation Number 7

Need Data

Full-Time

Occupation Number 8

Need Data

Additional Comments:

Reporting Example: (Hrs. Earned per Required Time Worked)

LEAVE BENEFITS: PERSONAL LEAVE

Last Date Reported:

Fill in Date

Date to Review Provisions:

Fill in Date

(Y/N) Have there been any changes to this policy since data was previously reported?
Please use the Current Update fields below to refresh previously reported data or to provide missing data.
If there is additional data to report, please indicate in the Additional Comments field.
Previously Reported Data

Current Update

Number of Days Provided:

Need Data

Is this part of a Consolidated Leave Plan?

Need Data

Pay Is Based On: (Base Pay, Avg Hrly Rate, Avg Hrly Rate+Shift):

Need Data

Employees eligible for paid personal leave:
Full-Time

Occupation Number 1

Need Data

Full-Time

Occupation Number 2

Need Data

Full-Time

Occupation Number 3

Need Data

Full-Time

Occupation Number 4

Need Data

Full-Time

Occupation Number 5

Need Data

Full-Time

Occupation Number 6

Need Data

Full-Time

Occupation Number 7

Need Data

Full-Time

Occupation Number 8

Need Data

Additional Comments:

SHIFT DIFFERENTIALS

Last Date Reported:

Fill in Date

Date to Review Provisions:

Fill in Date

(Y/N) Have there been any changes to this policy since data was previously reported?
Please use the Current Update fields below to refresh previously reported data or to provide missing data.
If there is additional data to report, please indicate in the Additional Comments field.
Previously Reported Data

Current Update

Full-Time

Occupation Number 1

Need Data

Full-Time

Occupation Number 2

Need Data

Full-Time

Occupation Number 3

Need Data

Full-Time

Occupation Number 4

Need Data

Full-Time

Occupation Number 5

Need Data

Full-Time

Occupation Number 6

Need Data

Full-Time

Occupation Number 7

Need Data

Full-Time

Occupation Number 8

Need Data

Additional Comments:

NON-PRODUCTION BONUS

Last Date Reported:

Fill in Date

Date Expected to Change:

Fill in Date

(Y/N) Have there been any changes to this policy since data was previously reported?
Please use the Current Update fields below to refresh previously reported data or to provide missing data.
If there is additional data to report, please indicate in the Additional Comments field.
Previously Reported Data

Current Update

Type of Bonus (i.e. Christmas, Hiring, Retention)

Need Data

Employees Eligible for Bonus:

Need Data

Days Until Eligible for Bonus:

Need Data

Benefit Payout Date:

Need Data

Provisions:
Flat Amount, Multiple of Earnings, Number of Days, Varies:

Need Data

Annual Non-Production Bonus per Occupation

Annual NP Bonus per Occupation for 2020

Full-Time

Occupation Number 1

Need Data

Full-Time

Occupation Number 2

Need Data

Full-Time

Occupation Number 3

Need Data

Full-Time

Occupation Number 4

Need Data

Full-Time

Occupation Number 5

Need Data

Full-Time

Occupation Number 6

Need Data

Full-Time

Occupation Number 7

Need Data

Full-Time

Occupation Number 8

Need Data

If annual occupational bonus amounts are not available, please provide a company-wide expenditure.
Non-Production Bonus Company-Wide Expenditure
Time Frame (Month / Quarter / Annual):

NPB Expenditure for 2021
Time Frame:

Company-Wide Expenditure:

Co-Wide Expenditure:

Company-Wide Employment:

Co-Wide Employment:

Company-Wide Gross Payroll:

Co-Wide Gross Payroll:

Additional Comments:

LIFE INSURANCE

Last Date Reported:

Fill in Date

Date Expected to Change:

Fill in Date

(Y/N) Have there been any changes to this policy since data was previously reported?
Please use the Current Update fields below to refresh previously reported data or to provide missing data.
If there is additional data to report, please indicate in the Additional Comments field.
LIFE INSURANCE PLAN CARRIER:

Need Data

Does the company contribute to the premium? (Y/N):

Need Data

If the answer is no, no additional information needed for this plan.

Previously Reported Data

Current Update

Policy Date:
Type of Insurance:

Need Data

Life Only, AD&D Only, Life & AD&D, Dependent Life:

Need Data

Plan Benefit:
Flat Amount, Multiple of Earnings, Varies:

Need Data

Amount:

Reporting Example:1x Annual Salary to Next Highest Thousand

Need Data
What is the Benefit Maximum?

Need Data

Is the employee required to contribute?

Need Data

Is Retiree Life offered?

Need Data

Employees Eligible for Life Insurance:

Need Data

Days Until Eligible for Life Insurance:

Need Data

Employees Participating in Plan (Count or Percent for each Occupation):
Full-Time Occupation Number 1
Need Data
Full-Time
Full-Time
Full-Time
Full-Time

Occupation Number 2
Occupation Number 3
Occupation Number 4
Occupation Number 5

Need Data
Need Data
Need Data
Need Data

Full-Time

Occupation Number 6

Need Data

Full-Time

Occupation Number 7

Need Data

Full-Time

Occupation Number 8

Need Data

Company Cost per $1000
Life Rate per $1000 per month:

Need Data

AD&D Rate per $1000 per month:

Need Data

Please specify whether reported participation is count or percent.

Company Cost per $1000 for 2021
Rate per $1000 / mo:
Rate per $1000 / mo:

If rates per $1000 are not available, or they vary by age or salary, please provide a company-wide expenditure.
Company-Wide Expenditure
Time Frame (Month / Quarter / Annual):

Co-Wide Expenditure for 2020
Time Frame:

Company-Wide Expenditure:

Co-Wide Expenditure:

Company-Wide Gross Payroll:

Co-Wide Gross Payroll:

Additional Comments:

HEALTH INSURANCE

Last Date Reported:

Fill in Date

Date Expected to Change:

Fill in Date

(Y/N) Have there been any changes to this policy since data was previously reported?
Please use the Current Update fields below to refresh previously reported data or to provide missing data.
If there is additional data to report, please indicate in the Additional Comments field.
If you can provide a copy of the current benefit guide with employer and employee premiums for health/dental/vision
or HSA plans, there is no need to duplicate the premium information on this page.
MEDICAL PLAN CARRIER:

Need Data

MEDICAL PLAN TIERS:

Need Data

Does the company contribute to the premium? (Y/N):

Need Data

If the answer is no, no additional information needed for this plan.

Previously Reported Data

Current Update

Fill in Plan Tier Name
Policy Date:

Need Data

Insurance Coverage:

Need Data

Does this plan pay benefits after services are rendered?

Need Data

Are there any restrictions on choice of plan providers?

Need Data

Does the employer pay any portion of claims for benefits?

Need Data

Does the employer have a stop loss insurance policy?

Need Data

Which employees are eligible for this plan?

Need Data

How many days before eligible for this plan:

Need Data

Employees Participating in Plan (Count or Percent for each Occupation):
Full-Time Occupation Number 1
Need Data
Full-Time

Occupation Number 2

Need Data

Full-Time

Occupation Number 3

Need Data

Full-Time

Occupation Number 4

Need Data

Full-Time

Occupation Number 5

Need Data

Full-Time

Occupation Number 6

Need Data

Full-Time

Occupation Number 7

Need Data

Full-Time

Occupation Number 8

Need Data

Previous Premiums:
Coverage
Options
Single:

Employer
Premiums
Need Data

Employee
Premiums
Need Data

Individual + Spouse:

Need Data

Need Data

Individual + Children:

Need Data

Need Data

Family:

Need Data

Need Data

Please specify whether reported participation is count or percent.

Current Update FY21-22
Employer
Premiums

Employee
Premiums

Fill in Plan Tier Name
Policy Date:

Need Data

Insurance Coverage:

Need Data

Does this plan pay benefits after services are rendered?

Need Data

Are there any restrictions on choice of plan providers?

Need Data

Does the employer pay any portion of claims for benefits?

Need Data

Does the employer have a stop loss insurance policy?

Need Data

Which employees are eligible for this plan?

Need Data

How many days before eligible for this plan:

Need Data

Employees Participating in Plan (Count or Percent for each Occupation):
Full-Time Occupation Number 1
Need Data
Full-Time

Occupation Number 2

Need Data

Full-Time

Occupation Number 3

Need Data

Full-Time

Occupation Number 4

Need Data

Full-Time

Occupation Number 5

Need Data

Full-Time

Occupation Number 6

Need Data

Full-Time

Occupation Number 7

Need Data

Full-Time

Occupation Number 8

Need Data

Previous Premiums:
Coverage
Options
Single:

Employer
Premiums
Need Data

Employee
Premiums
Need Data

Individual + Spouse:

Need Data

Need Data

Individual + Children:

Need Data

Need Data

Family:

Need Data

Need Data

Please specify whether reported participation is count or percent.

Current Update FY21-22
Employer
Premiums

Employee
Premiums

Fill in Plan Tier Name
Policy Date:

Need Data

Insurance Coverage:

Need Data

Does this plan pay benefits after services are rendered?

Need Data

Are there any restrictions on choice of plan providers?

Need Data

Does the employer pay any portion of claims for benefits?

Need Data

Does the employer have a stop loss insurance policy?

Need Data

Which employees are eligible for this plan?

Need Data

How many days before eligible for this plan:

Need Data

Employees Participating in Plan (Count or Percent for each Occupation):
Full-Time Occupation Number 1
Need Data
Full-Time

Occupation Number 2

Need Data

Full-Time

Occupation Number 3

Need Data

Full-Time

Occupation Number 4

Need Data

Full-Time

Occupation Number 5

Need Data

Full-Time

Occupation Number 6

Need Data

Full-Time

Occupation Number 7

Need Data

Full-Time

Occupation Number 8

Need Data

Previous Premiums:
Coverage
Options
Single:

Employer
Premiums
Need Data

Employee
Premiums
Need Data

Individual + Spouse:

Need Data

Need Data

Individual + Children:

Need Data

Need Data

Family:

Need Data

Need Data

Please specify whether reported participation is count or percent.

Current Update FY21-22
Employer
Premiums

Employee
Premiums

If premiums are not available, please provide a company-wide expenditure.
Previous Health Insurance Expenditure
Time Frame (Month / Quarter / Annual):

Health Insurance Expenditure for 2021
Time Frame:

Company-Wide Expenditure:

Co-Wide Expenditure:

Total Number of Eligible Employees:

Tot. # Elig Employees:

HSA Company Contribution
Does the company contribute to the HSA? (Y/N):

Need Data

If the answer is yes, please answer the following expenditure questions.

Previous HSA Company Contribution Expenditure
Monthly Company Contribution Amount:

HSA Co. Contribution Expenditure for 2021
Monthly Contribution:

Total Company-Wide Expenditure:

Co-Wide Expenditure:

Total Number of Eligible Employees:

Tot. # Elig Employees:

Additional Comments:

DENTAL PLAN CARRIER:

Need Data

DENTAL PLAN TIERS:

Need Data

Does the company contribute to the premium? (Y/N):

Need Data

If the answer is no, no additional information needed for this plan.

Previously Reported Data

Current Update

Policy Date:

Need Data

Does this plan pay benefits after services are rendered?

Need Data

Are there any restrictions on choice of plan providers?

Need Data

Does the employer pay any portion of claims for benefits?

Need Data

Does the employer have a stop loss insurance policy?

Need Data

Which employees are eligible for this plan?

Need Data

How many days before eligible for this plan:

Need Data

Employees Participating in Plan (Count or Percent for each Occupation):
Full-Time Occupation Number 1
Need Data
Full-Time

Occupation Number 2

Need Data

Full-Time

Occupation Number 3

Need Data

Full-Time

Occupation Number 4

Need Data

Full-Time

Occupation Number 5

Need Data

Full-Time

Occupation Number 6

Need Data

Full-Time

Occupation Number 7

Need Data

Full-Time

Occupation Number 8

Need Data

Previous Premiums:
Coverage
Options
Single:
Family:

Employer
Premiums
Need Data

Employee
Premiums
Need Data

Need Data

Need Data

Please specify whether reported participation is count or percent.

Current Update FY21-22
Employer
Premiums

Employee
Premiums

If premiums are not available, please provide a company-wide expenditure.
Previous Dental Insurance Expenditure
Time Frame (Month / Quarter / Annual):

Dental Insurance Expenditure for 2021
Time Frame:

Expenditure:

Expenditure:

Number of Eligible Employees:

Eligible Employees:

Additional Comments:

VISION PLAN CARRIER:

Need Data

VISION PLAN TIERS:

Need Data

Does the company contribute to the premium? (Y/N):

Need Data

If the answer is no, no additional information needed for this plan.

Previously Reported Data

Current Update

Policy Date:

Need Data

Does this plan pay benefits after services are rendered?

Need Data

Are there any restrictions on choice of plan providers?

Need Data

Does the employer have a stop loss insurance policy?

Need Data

Which employees are eligible for this plan?

Need Data

How many days before eligible for this plan:

Need Data

Employees Participating in Plan (Count or Percent for each Occupation):
Full-Time Occupation Number 1
Need Data
Full-Time

Occupation Number 2

Need Data

Full-Time

Occupation Number 3

Need Data

Full-Time

Occupation Number 4

Need Data

Full-Time

Occupation Number 5

Need Data

Full-Time

Occupation Number 6

Need Data

Full-Time

Occupation Number 7

Need Data

Full-Time

Occupation Number 8

Need Data

Previous Premiums:
Coverage
Options
Single:

Employer
Premiums
Need Data

Employee
Premiums
Need Data

Individual + Spouse:

Need Data

Need Data

Individual + Children:

Need Data

Need Data

Family:

Need Data

Need Data

Please specify whether reported participation is count or percent.

Current Update FY21-22
Employer
Premiums

If premiums are not available, please provide a company-wide expenditure.
Previous Vision Insurance Expenditure
Time Frame (Month / Quarter / Annual):

Time Frame:

Expenditure:

Expenditure:

Number of Eligible Employees:

Eligible Employees:

Additional Comments:

Employee
Premiums

SHORT-TERM DISABILITY INSURANCE

Last Date Reported:

Fill in Date

Date to Review Provisions:

Fill in Date

(Y/N) Have there been any changes to this policy since data was previously reported?
Please use the Current Update fields below to refresh previously reported data or to provide missing data.
If there is additional data to report, please indicate in the Additional Comments field.
Previously Reported Data

Current Update

Short-Term Disability Plan: (Paid, Unpaid, or No Plan):

Need Data

Days Until Eligible for Short-Term Disability:

Need Data

Short-Term Disability Sponsor:
Unfunded - Salary Continuation:

Need Data

Self-Insured:

Need Data

Insured - Commercial, union, association:

Need Data

Insurance Carrier:

Need Data

State Plan - Legally Required:

Need Data

Other

Need Data

Short-Term Disability Plan Formula:
Percent of Earnings:

Need Data

Maximum weekly amount:

Need Data

Duration of Benefits:

Need Data

Employee Contribution to Plan:

Need Data

Employees Participating in Plan (Count or Percent for each Occupation):
Full-Time Occupation Number 1
Need Data
Full-Time Occupation Number 2
Need Data
Full-Time Occupation Number 3
Need Data
Full-Time Occupation Number 4
Need Data
Full-Time Occupation Number 5
Need Data
Full-Time Occupation Number 6
Need Data
Full-Time Occupation Number 7
Need Data
Full-Time Occupation Number 8
Need Data

Please specify whether reported participation is count or percent.

Previous Estimated Annual Usage (Days Used)
Full-Time Occupation Number 1
Full-Time Occupation Number 2
Full-Time Occupation Number 3
Full-Time Occupation Number 4
Full-Time Occupation Number 5
Full-Time Occupation Number 6
Full-Time Occupation Number 7
Full-Time Occupation Number 8
Additional Comments:

Estimated Annual Usage
Need Data
Need Data
Need Data
Need Data
Need Data
Need Data
Need Data
Need Data

LONG-TERM DISABILITY INSURANCE

Last Date Reported:

Fill in Date

Date to Review Provisions:

Fill in Date

(Y/N) Have there been any changes to this policy since data was previously reported?
Please use the Current Update fields below to refresh previously reported data or to provide missing data.
If there is additional data to report, please indicate in the Additional Comments field.
Previously Reported Data

Current Update

Long-Term Disability Plan: (Paid, Unpaid, or No Plan)

Need Data

Days Until Eligible for Long-Term Disability:

Need Data

Insurance Carrier:

Need Data

Policy Date:

Need Data

Long-Term Disability Plan Formula:
Percent of Earnings:

Need Data

Maximum monthly amount:

Need Data

Employee Contribution to Plan:

Need Data

Employees Participating in Plan (Count or Percent for each Occupation):
Full-Time Occupation Number 1
Need Data
Full-Time

Occupation Number 2

Need Data

Full-Time

Occupation Number 3

Need Data

Full-Time

Occupation Number 4

Need Data

Full-Time

Occupation Number 5

Need Data

Full-Time

Occupation Number 6

Need Data

Full-Time

Occupation Number 7

Need Data

Full-Time

Occupation Number 8

Need Data

Company Cost per $100
Rate per $100 per employee:
Additional Comments:

Need Data

Please specify whether reported participation is count or percent.

Company Cost per $100 for 2021
Rate per $100 / EE:

RETIREMENT:

DEFINED BENEFIT

Last Date Reported:

Fill in Date

Date Expected to Change:

Fill in Date

(Y/N) Have there been any changes to this policy since data was previously reported?
Please use the Current Update fields below to refresh previously reported data or to provide missing data.
If there is additional data to report, please indicate in the Additional Comments field.
RETIREMENT PLAN:

Need Data

Previously Reported Data

Current Update FY21-22

Plan Description Year:

Need Data

Days Until Eligible to Participate in Plan:

Need Data

Employee Contribution to Plan:

Need Data

Are benefits frozen or are they accruing for participants?

Need Data

Are new employees able to participate in this plan?
IF NO:

Need Data

What year did new employees become ineligible for plan?

Need Data

What other retirement benefits are available for new
employees who could not participate in this plan?
A new defined benefits plan:

Need Data

A modified version of the existing plan:

Need Data

A new defined contributions plan:

Need Data

An enhanced defined contribution plan:

Need Data

Other:

Need Data

Nothing replaced this plan:

Need Data

Employees Participating in Plan (Count or Percent for each Occupation):
Full-Time Occupation Number 1
Need Data
Full-Time

Occupation Number 2

Need Data

Full-Time

Occupation Number 3

Need Data

Full-Time

Occupation Number 4

Need Data

Full-Time

Occupation Number 5

Need Data

Full-Time

Occupation Number 6

Need Data

Full-Time

Occupation Number 7

Need Data

Full-Time

Occupation Number 8

Need Data

Please specify whether reported participation is count or percent.

Previous Employer Contribution to Plan:

Need Data

If participation is not available, please provide a company-wide expenditure.
Expenditure Cost:

Expenditure Cost:

Number of Employees:

Number of Employees:

Gross Payroll:

Gross Payroll:

Additional Comments:

RETIREMENT PLAN:

Need Data

Previously Reported Data

Current Update FY21-22

Plan Description Year:

Need Data

Days Until Eligible to Participate in Plan:

Need Data

Employee Contribution to Plan:

Need Data

Are benefits frozen or are they accruing for participants?

Need Data

Are new employees able to participate in this plan?
IF NO:

Need Data

What year did new employees become ineligible for plan?

Need Data

What other retirement benefits are available for new
employees who could not participate in this plan?
A new defined benefits plan:

Need Data

A modified version of the existing plan:

Need Data

A new defined contributions plan:

Need Data

An enhanced defined contribution plan:

Need Data

Other:

Need Data

Nothing replaced this plan:

Need Data

Employees Participating in Plan (Count or Percent for each Occupation):
Full-Time Occupation Number 1
Need Data
Full-Time

Occupation Number 2

Need Data

Full-Time

Occupation Number 3

Need Data

Full-Time

Occupation Number 4

Need Data

Full-Time

Occupation Number 5

Need Data

Full-Time

Occupation Number 6

Need Data

Full-Time

Occupation Number 7

Need Data

Full-Time

Occupation Number 8

Need Data

Please specify whether reported participation is count or percent.

Previous Employer Contribution to Plan:

Need Data

If participation is not available, please provide a company-wide expenditure.
Expenditure Cost:

Expenditure Cost:

Number of Employees:

Number of Employees:

Gross Payroll:

Gross Payroll:

Additional Comments:

RETIREMENT:

DEFINED CONTRIBUTION

Last Date Reported:

Fill in Date

Date Expected to Change:

Fill in Date

(Y/N) Have there been any changes to this policy since data was previously reported?
Please use the Current Update fields below to refresh previously reported data or to provide missing data.
If there is additional data to report, please indicate in the Additional Comments field.
Previously Reported Data

Current Update

Plan Description Title:

Need Data

Days Until Eligible to Participate in Plan:

Need Data

Plan Type
(Def Profit Share, ESOP, MPP, Svgs & Thrift, SEP, SIMPLE)

Need Data

Must employee contribute to receive employer contribution?

Need Data

Are any employee contributions tax-deferred?

Need Data

Employees Participating in Plan (Count or Percent for each Occupation):
Full-Time Occupation Number 1
Need Data
Full-Time

Occupation Number 2

Need Data

Full-Time

Occupation Number 3

Need Data

Full-Time

Occupation Number 4

Need Data

Full-Time

Occupation Number 5

Need Data

Full-Time

Occupation Number 6

Need Data

Full-Time

Occupation Number 7

Need Data

Full-Time

Occupation Number 8

Need Data

Previous Employer Contribution to Plan:

Please specify whether reported participation is count or percent.

Need Data

If participation is not available, please provide a company-wide expenditure.

Additional Comments:

Expenditure Cost:

Expenditure Cost:

Number of Employees:

Number of Employees:

Gross Payroll:

Gross Payroll:

STATE UNEMPLOYMENT INSURANCE

Last Date Reported:

Fill in Date

Date Expected to Change:

Fill in Date

(Y/N) Have there been any changes to this policy since data was previously reported?
Please use the Current Update fields below to refresh previously reported data or to provide missing data.
If there is additional data to report, please indicate in the Additional Comments field.
Previous State Unemployment Insurance Rate for 2020

State Unemployment Insurance Rate 2021
Need Data

Previous State Unemployment Insurance Expenditure

Expenditure for 2020

Time Frame (Month / Quarter / Annual):

Need Data

Time Frame:

Expenditure:

Need Data

Expenditure:

Total Employment:

Need Data

Total Employment:

Additional Comments:

WORKER'S COMPENSATION

Last Date Reported:

Fill in Date

Date Expected to Change:

Fill in Date

(Y/N) Have there been any changes to this policy since data was previously reported?
Please use the Current Update fields below to refresh previously reported data or to provide missing data.
If there is additional data to report, please indicate in the Additional Comments field.
Previously Reported Data

Current Update

Plan Carrier:

Need Data

Policy Date:

Need Data

Worker's Comp Code

Cost per $100

Need Data Occupation Number 1

Need Data

Need Data Occupation Number 2

Need Data

Need Data Occupation Number 3

Need Data

Need Data Occupation Number 4

Need Data

Need Data Occupation Number 5

Need Data

Need Data Occupation Number 6

Need Data

Need Data Occupation Number 7

Need Data

Need Data Occupation Number 8

Need Data

Current Update FY21-22
WC Code
(if available)

Experience Modifier in decimal (if applicable):

Need Data

Experience Modifier 2021:

Premium Discount in decimal (if applicable):

Need Data

Premium Discount 2021:

If rates per $100 per occupation are not available, please provide an expenditure below.
Worker's Compensation Expenditure
Time Frame (Month / Quarter / Annual):

Expenditure for 2021
Time Frame:

Worker's Comp Expenditure:

WC Expenditure:

Total Employees:

Total Employees:

Gross Payroll:

Gross Payroll:

Additional Comments:

Cost per $100

OTHER BENEFITS

Last Date Reported:

Fill in Date

Date Expected to Change:

Fill in Date

(Y/N) Have there been any changes to the benefits offered below since data was previously reported?

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 Account (HSA)
Flexible Benefits
Health Flexible Spending Account
Dependent Care Flex Spending Account
Cash/Defer'd Arrangement; no ER Contribution

Payroll Deduction IRA; no ER Contribution
Financial Planning
Student Loan Repayment
Long-term Care Insurance
Retiree Health - Under age 65
Retiree Health - Age 65 and Over
Domestic Partner Health Same Sex
Domestic Partner Health Opposite Sex
Domestic Partner DB Survivor Same Sex
Domestic Partner DB Survivor Opposite Sex

All

Oc

Previously Reported Data (Please insert "y" for any benefits offered.)

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n
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n
cu
1
pa N u
m
Oc tio
b
er
n
cu
2
pa N u
m
Oc tio
b
er
n
cu
3
pa N u
m
Oc tio
be
n
cu
r4
pa N u
m
t
Oc
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be
n
cu
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N
pa
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Oc
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be
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cu
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Please use the Current Update fields below to refresh previously reported data or to provide missing data.
If there is additional data to report, please indicate in the Additional Comments field.

Additional Comments:


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File Modified2021-05-17
File Created2021-03-25

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