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pdfBureau 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
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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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2
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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:
| File Type | application/pdf |
| File Modified | 2021-05-17 |
| File Created | 2021-03-25 |