NCS SO Statement of Benefits Example

National Compensation Survey Schedule # - 999999

Employment Cost Index

Month Year Update {Index benefits summary only – Private industry}

Thank you for your assistance with the Employment Cost Index. Your summary of benefits report is enclosed. Please update the plan information and costs within one week of receiving this package. Include any scheduled changes effective before the reference date of MONTH 12, YEAR. If there are significant changes, we may need to follow up with you to get more details.

There are several reporting options available:

• Secure file transfer over the internet – https://www.BLSCompdata.bls.gov

• Email to BLSCompdata@bls.gov

• Fax the completed form to 999-999-9999

• Mail a printed report or the completed form

Data can be reported in any standard format, but be sure to include your schedule number, 999999, on any reports or emails.

If you have any questions, please contact: XXXX XXXXXXX at 999-999-8888.

Please correct name, title, or address, as needed. Respondent Name

Prepared by: Respondent Title

Name ____________ Company Name

Title ____________ Company Name 2

Telephone: ________________________ Address1

Address2

Date Prepared: City, State Zip

As entered by the regional office

As a participant in a Bureau of Labor Statistics (BLS) statistical survey, you should be aware that use of electronic transmittal methods in reporting data to the BLS involves certain

inherent risks to the confidentiality of those data. Further, you should be aware that responsible electronic transmittal practices employed by the BLS cannot completely eliminate

those risks.

The BLS is committed to the responsible treatment of the data you report and will take appropriate steps within its ability to protect the confidentiality of those data.

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 XXXXXX
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.

(NOTE: This is a computer-generated form that provides prior benefits data to, and requests updated benefits data from survey respondents)

Summary of Benefits (Government) example – update

U. S. DEPARTMENT OF LABOR BUREAU OF LABOR STATISTICS SO-1003P PAGE 1

Establishment = Any Company Schedule Number = XXXXXXX

Mr. Xxxx Xxxxx, CEO

(TEL.) Number

Ben #		Plan description	Expected to change
BENEFIT DESCRIPTIONS COVER THE FOLLOWING OCCUPATIONS XXXX Division Manager XXXX Head Technician XXXX Secretary XXXX Janitor
01	WORK SCHEDULE – Full-time and part-time
	Full-time 8.00 hours/day 40.00/weekly hours 52.0 annual weeks
	Part-time 5.00 hours/day 25.00/weekly hours 52.0 annual weeks
01	1.5X after 40 hours/wk, 2.0X on Sundays
02	VACATION
	After 6 months = 1 week
	After 1 year = 2 weeks
	After 5 years = 3 weeks
	After 10 years = 4 weeks (max.)

Summary of Benefits example – update

U. S. DEPARTMENT OF LABOR BUREAU OF LABOR STATISTICS

Establishment = Any Company Schedule Number = XXXXXX

Ben #	Plan description				Expected to change
03	HOLIDAYS
	8 paid holidays a year.
	New Year’s Day President’s Day Memorial Day July 4th		Labor Day Veteran’s Day Thanksgiving Christmas
04	SICK LEAVE
	5 days/year. No carry over.
05	OTHER LEAVE
	Auxiliary Leave
	Funeral leave: 3 days. Immediate family.
	Personal leave: 2 days/year.
	Jury duty: As needed. Unpaid
07	NONPRODUCTION BONUS
	Year end bonus				12/01/1X
	Year-end bonus: 1 weeks pay.
10	LIFE INSURANCE
	All: $10,000 Life & AD&D. 50% employer paid.				09/01/1X
	Total cost: Life = $.70/$1,000/month
	AD&D = $.07/$1,000/month
	Optional plan 100% employee paid.
11	HEALTH BENEFITS
	Blue Cross/Blue Shield				10/31/1X
	Eligibility=	3 month LOS, Full-Time
	2018	HEALTH PROVISIONS		EMPLOYER (70%)	EMPLOYEE (30%)
		Total cost: Single = $212.34/month
		Family = $458.16/month
12	SHORT TERM DISABILITY INSURANCE
	Optional plan. 100% employee paid.				10/01/1X

Summary of Benefits example – update

U. S. DEPARTMENT OF LABOR BUREAU OF LABOR STATISTICS

Establishment = Any Company Schedule Number = XXXXX

BEN #	PLAN DISCRIPTION					EXPECTED TO CHANGE
	PLEASE PROVIDE 2018 RATE
23	LONG TERM DISABILITY PAY					11/01/1X
	Full-time:	Benefit = 60% of salary up to $4,000/month until retirement age. 2010 TOTAL COST = $.70/$100 of payroll Company pays 50% Employee pays 50%
13	DEFINED BENEFIT PENSION PLANS
	Pension plan:		Pays 2.0%X years of service
	201X Fiscal Year:		Co. Cost = $ 189,359.00
			Co. gross payroll = $2,310,922.00
	Eligibility:		Must work over 1,000 hrs/year.
	PLEASE PROVIDE 2004RATE.
20	STATE UNEMPLOYMENT INSURANCE
	201X rate = 2.4%					10/01/1X
21	WORKER’S COMPENSATION					06/01/1X
	201X Rates
	Office 8810 =			$.27/$100.00
	Sales workers 8742 =			$.89/$100.00
	Experience Modifier =			1.15
	Premium Discount =			9.0%
22	THERE ARE NO PROVISIONS FOR THE FOLLOWING BENEFITS:
	Defined Contribution Plan