Download:
pdf |
pdfBureau of Labor Statistics
U.S. Department of Labor
[Month Year] Update
OMB No.
Expiration Date:
1220-0164
5/31/2024
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 at [email protected]. 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:
Holidays
Please update links when updates occur.
Health Insurance information
Benefits Overview
Pay Tables
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 Email Address, and Telephone Number]
We are collecting benefit information on the following occupations:
Selected Job
Salesperson
Clerical
Warehouse Supervisor
Benefits Reported:
NCS Form: SO100BF-1GP
FT/PT
FT
FT
FT
-
Wage Type
Incentive
Time
Time
FLSA
Exempt
Non-exempt
Exempt
Union Status
Non-union
Non-union
Non-union
Hrs/Dy
8
8
8
Hrs/Wk
40
40
40
Wks/Yr
52
52
52
OVERTIME PREMIUM PAY
Last Date Reported:
Date to Review Provisions:
March 1, 2023
March 2024
(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)
Daily After:
Hours
1.5
Weekly After:
40
Current Update
Reporting Example: (Premium Paid per OT Event )
Hours
Weekly After:
Hours
Weekends:
Holidays:
Holidays:
Other:
Other:
FT
Salesperson
FT
Clerical
FT
Warehouse Supervisor
-
-
-
-
-
-
-
-
-
-
NCS Form: SO100BF-1GP
Hours
Weekends:
Estimated Annual Overtime Usage per Occupation (Hours)
Additional Comments:
Daily After:
Est. Annual Usage per Occupation for 2020
N/A
N/A
24
N/A
N/A
LEAVE BENEFITS:
VACATION
Last Date Reported:
Date to Review Provisions:
March 1, 2023
March 2024
(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:
Yes
Days Until Eligible for Paid Vacation Leave:
1 Year
Is this a Consolidated Leave Plan?
No
If yes, what leave is included?
Accrual Per Pay Period : Reporting Example: (Hrs. Earned per Required Time Employed)
Vacation Hours Earned
Required Time Employed
40
1 year
Hours
Year(s)
80
2 years
Hours
Year(s)
120
5 years
Hours
Year(s)
Pay Is Based On: (Base Pay, Avg Hrly Rate, Avg Hrly Rate+Shift):
Additional Comments:
NCS Form: SO100BF-1GP
Reporting Example: (Hrs. Earned per Required Time Employed)
Base Pay
LEAVE BENEFITS: HOLIDAYS
Last Date Reported:
March 1, 2023
Date Expected to Change:
(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
Some
Days Until Eligible for Holiday Leave:
Immediate
Is the Workplace Open on Holidays?
Some
Estimate percent of employees working holidays:
Need Data
Are Employees Paid Holiday Overtime if they work?
Yes
If Yes, What is The Overtime Rate?
1.5
If no, pay Is Based On:(Base Pay, Avg Hrly Rate, Avg Hrly Rate+Shift):
Number of Paid Holidays:
New Year's Eve
New Year's Day
Martin Luther King Day
President's Day
Good Friday
Memorial Day
Juneteenth
July 4th
Labor Day
Columbus Day
Election Day
Veteran's Day
Thanksgiving Day
Day after Thanksgiving
Christmas Eve
Christmas Day
Employee Birthday
Floating Holiday
Easter
Open*
Open*
Open*
Closed
Closed
Closed
If Other, please list:
Additional Comments:
NCS Form: SO100BF-1GP
Store is closed for these paid holidays: Easter, Thanksgiving, and Christmas Day. *Clerical and
Warehouse receive 1.5 x pay if they work on: Memorial Day, Labor day, 4th of July.
Salespeople do not receive paid holiday off or premium pay for worked holidays.
LEAVE BENEFITS:
SICK LEAVE
Last Date Reported:
Date to Review Provisions:
March 1, 2023
March 2024
(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
Employees Eligible for Unpaid Sick Leave
Current Update
Salespeople
Employees Eligible for Paid Sick Leave
All others
Days Until Eligible for Paid Sick Leave:
Immeditate
Maximum Days of Paid Sick Leave Per Year:
3
Accrual Policy:
Reporting Example: (Hrs. Earned per Required Time Worked)
Sick Leave Hours Earned
Required Work Time
24
per
2080 Hrs Worked
Pay Is Based On: (Base Pay, Avg Hrly Rate, Avg Hrly Rate+Shift):
Reporting Example: (Hrs. Earned per Required Time Worked)
Hrs Per
Base
Is this a Consolidated Leave Plan?
No
If yes, what leave is included?
N/A
Unused Sick Leave: (Cash In or Carry Over)
No
If Carry Over, how much?
Estimated Annual Sick Leave Usage per Occupation (Hours)
FT
Salesperson
N/A
FT
Clerical
3
FT
Warehouse Supervisor
3
-
-
-
-
-
-
-
-
-
-
Additional Comments: Estimated all Clerical and Warehouse Supervisors use all 3 days.
NCS Form: SO100BF-1GP
Hrs Worked
LEAVE BENEFITS: PERSONAL LEAVE
Last Date Reported:
Date to Review Provisions:
March 1, 2023
March 2024
(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:
FT
Salesperson
Need Data
FT
Clerical
Need Data
FT
Warehouse Supervisor
Need Data
-
-
-
-
-
-
-
-
-
-
Additional Comments: Can employees use vacation for personal days?
NCS Form: SO100BF-1GP
NON-PRODUCTION BONUS
Last Date Reported:
Date Expected to Change:
March 1, 2023
March 2024
(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
Type of Bonus (i.e. Christmas, Hiring, Retention)
Current Update
Christmas
Employees Eligible for Bonus:
Yes
Days Until Eligible for Bonus:
Immediate
Benefit Payout Date:
Provisions:
Flat Amount, Multiple of Earnings, Number of Days, Varies:
1-Dec
Flat Amount
Annual Non-Production Bonus per Occupation
Annual NP Bonus per Occupation for 2023
FT
Salesperson
$250
FT
Clerical
$250
FT
Warehouse Supervisor
$250
-
-
-
-
-
-
-
-
-
-
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 2023
Time Frame:
Company-Wide Expenditure:
Co-Wide Expenditure:
Company-Wide Employment:
Co-Wide Employment:
Company-Wide Gross Payroll:
Co-Wide Gross Payroll:
Additional Comments:
NCS Form: SO100BF-1GP
LIFE INSURANCE
Last Date Reported:
Date Expected to Change:
March 1, 2023
March 2024
(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:
Does the company contribute to the premium? (Y/N):
If the answer is no, no additional information needed for this plan.
Need Data
Yes
Previously Reported Data
Policy Date:
Type of Insurance:
Current Update
Need Data
Life Only, AD&D Only, Life & AD&D, Dependent Life:
Life only
Plan Benefit:
Flat Amount, Multiple of Earnings, Varies:
Flat Amount
Amount:
Reporting Example:1x Annual Salary to Next Highest Thousand
$30,000
What is the Benefit Maximum?
Is the employee required to contribute?
Is Retiree Life offered?
$30,000
No
Need Data
Employees Eligible for Life Insurance:
Yes
Days Until Eligible for Life Insurance:
60 days
Employees Participating in Plan (Count or Percent for each Occupation):
FT
Salesperson
100%
FT
Clerical
100%
FT
Warehouse Supervisor
100%
-
-
-
-
-
-
-
-
-
-
Company Cost per $1000
Life Rate per $1000 per month:
$5.40
AD&D Rate per $1000 per month:
N/A
NCS Form: SO100BF-1GP
Please specify whether reported participation is count or percent.
Company Cost per $1000 for 2024
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:
NCS Form: SO100BF-1GP
HEALTH INSURANCE
Last Date Reported:
Date Expected to Change:
March 1, 2023
March 2024
(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:
BC/BS
MEDICAL PLAN TIERS:
1
Does the company contribute to the premium? (Y/N):
Y
If the answer is no, no additional information needed for this plan.
Previously Reported Data
Current Update
Fill in Plan Tier Name
Policy Date:
1/1/2023
Insurance Coverage:
Medical/Prescription
Does this plan pay benefits after services are rendered?
Yes
Are there any restrictions on choice of plan providers?
No
Does the employer pay any portion of claims for benefits?
No
Does the employer have a stop loss insurance policy?
No
Which employees are eligible for this plan?
How many days before eligible for this plan:
All FT
60
Employees Participating in Plan (Count or Percent for each Occupation):
FT
Salesperson
100%
FT
Clerical
50%
FT
Warehouse Supervisor
75%
-
-
-
-
-
-
-
-
-
-
Previous Premiums:
Coverage
Options
Employer
Premiums
(monthly)
$397.79
Employee
Premiums
(monthly)
$24.50
Individual + Spouse:
$397.79
$184.27
Individual + Children:
$397.79
$292.40
Family:
$397.79
$305.76
Single:
NCS Form: SO100BF-1GP
Please specify whether reported participation is count or percent.
Current Update FY24
Employer
Premiums
(monthly)
Employee
Premiums
(monthly)
If premiums are not available, please provide a company-wide expenditure.
Previous Health Insurance Expenditure
Time Frame (Month / Quarter / Annual):
Health Insurance Expenditure for 2023
Time Frame:
Company-Wide Expenditure:
Co-Wide Expenditure:
Total Number of Eligible Employees:
Tot. # Elig Employees:
Additional Comments:
NCS Form: SO100BF-1GP
LONG-TERM DISABILITY INSURANCE
Last Date Reported:
Date to Review Provisions:
March 1, 2023
March 2024
(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)
Paid
Days Until Eligible for Long-Term Disability:
365
Insurance Carrier:
Policy Date:
Need Data
1/1/2023
Long-Term Disability Plan Formula:
Percent of Earnings:
Maximum monthly amount:
Employee Contribution to Plan:
66%
$5,000
No
Employees Participating in Plan (Count or Percent for each Occupation):
FT
Salesperson
100
FT
Clerical
100
FT
Warehouse Supervisor
100
-
-
-
-
-
-
-
-
-
-
Company Cost per $100
Rate per $100 per employee:
Additional Comments:
NCS Form: SO100BF-1GP
$0.47
Please specify whether reported participation is count or percent.
Company Cost per $100 for 2021
Rate per $100 / EE:
RETIREMENT:
DEFINED CONTRIBUTION
Last Date Reported:
Date Expected to Change:
March 2024
(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:
401(k)
Days Until Eligible to Participate in Plan:
Plan Type
(Def Profit Share, ESOP, MPP, Svgs & Thrift, SEP, SIMPLE)
365
401(k)
Must employee contribute to receive employer contribution?
Yes
Are any employee contributions tax-deferred?
Yes
Employees Participating in Plan (Count or Percent for each Occupation):
FT
Salesperson
Need Data
FT
Clerical
Need Data
FT
Warehouse Supervisor
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.
Expenditure Cost:
Expenditure Cost:
Number of Employees:
Number of Employees:
Gross Payroll:
Gross Payroll:
Additional Comments:
NCS Form: SO100BF-1GP
WORKER'S COMPENSATION
Last Date Reported:
Date Expected to Change:
March 2024
(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 Salesperson
Need Data
Need Data Clerical
Need Data
Need Data Warehouse Supervisor
Need Data
Current Update FY24
WC Code
(if available)
Experience Modifier in decimal (if applicable):
Need Data
Experience Modifier 2024:
Premium Discount in decimal (if applicable):
Need Data
Premium Discount 2024:
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 2023
Time Frame:
Worker's Comp Expenditure:
WC Expenditure:
Total Employees:
Total Employees:
Gross Payroll:
Gross Payroll:
Additional Comments:
NCS Form: SO100BF-1GP
Cost per $100
OTHER BENEFITS
Last Date Reported:
March 1, 2023
Date Expected to Change:
March 2024
(Y/N) Have there been any changes to the benefits offered below since data was previously reported?
Cl
-
-
-
-
es
All
Sa
l
Previously Reported Data (Please insert "y" for any benefits offered.)
pe
r
e r so n
ica
W l
ar
eh
ou
se
Su
pe
rv
iso
r
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.
Y
--
--
--
--
--
--
--
--
Health Flexible Spending Account
Y
--
--
--
--
--
--
--
--
Dependent Care Flex Spending Account
Y
--
--
--
--
--
--
--
--
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
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
NCS Form: SO100BF-1GP
NCS Form: SO100BF-1GP
Additional Comments:
NCS Form: SO100BF-1GP
| File Type | application/pdf |
| Author | Kirby, Brian - BLS |
| File Modified | 2023-11-21 |
| File Created | 2023-10-03 |