Form NCS 11-5G NCS 11-5G Benefits Form

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.	Form Approved O.M.B. #1220-0164 Expires 1/31/14
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BENEFITS COLLECTION FORM FOR GOVERMENT

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
Other 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 11-5G (September 2010)

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. # _______________________

Company Provisions

HEALTH

Does the establishment offer health insurance benefits to any employees?

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: _______________________

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:

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. # _______________________

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

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): __________

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: _______________________

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	.	.
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:

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: _______________________

S Sick leave plan: ___Days paid as needed __ Max. days per year __ Other (specify) __ Not determinable chedule	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:

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 _____/______/_____

OTHER LEAVE (Benefit 05) Sched. #_______________________

Date of expected change (DOEC): __________

Leave Plan	Quotes Covered	Eligibility	Paid Days	Payment Rate	Unpaid Days
Funeral Leave
Jury Duty Leave
Military Leave
Family Leave
Personal Leave
Other (specify) Paid Leave
Leave Without Pay

Quote

Personal

Funeral

Military

Jury Duty

Family

Other

Occ. Employ.

Paid

Unpaid

Paid

Unpaid

Paid

Unpaid

Paid

Unpaid

Paid

Unpaid

Paid

Unpaid

1

2

3

4

5

6

7

8

Remarks/Calculations:

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: _______________________

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; *1^st 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:

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: _______________________

	Plan Type	Provisions/Benefit Formula
	Attendance
	Cash profit sharing
	Employee recognition program
	End-of-year discretionary bonus
	Hiring
	In-lieu of benefit payment
	Referral
	Retention
	Safety
	Signing
	Suggestion
	Union-related
	Other (specify)
	Not determinable

Usage/Cost:

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: _______________________

Plan No.	Name	Type
01
02
03

Remarks/Calculations:

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. #_______________________

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)

HEALTH INSURANCE (Benefit 11) Sched. #_______________________

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

3. 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?

3. 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. # _______________________

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: _______________________

Remarks/Calculations:

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. # _______________________

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: _______________________

Remarks/Calculations:

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. # _______________________

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: _______________________

Remarks/Calculations:

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. ________

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: _______________________

Remarks/Calculations:

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. #_________

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: _______________________

Remarks/Calculations:

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): __________

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. # _______________________

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 ____/_____/____

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 ____/_____/____

Emerging Benefits Sched. # _______________________

Date of expected change (DOEC): ___________

Eligibility: _______________________ Plan name: ________________________

Benefit

Access for each benefit

Quotes

ND*

All

None

1

2

3

4

5

6

7

8

Child Care Assistance

Retiree Health – under age 65

Retiree Health – age 65 and over

Financial Planning

Wellness Programs

Employee Assistance Program

Subsidized Commuting

Long-term Care Insurance

Flexible Workplace

Health Savings Accounts (HAS)

Cash Defer’d Arrangement, no ER contribution

Fexible Benefits

Health Care Reimbursement Account

Dependent Care Reimbursement Accts

Stock Option - Other

Stock Option - Performance

Stock Option - Signing

Paid Funeral Leave

Paid Military Leave

Paid Personal Leave

Paid Family Leave

Unpaid Family Leave

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

Other 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