Total Compensation Statement Questionnaire:

Broker______
Group Name______
HR Administrator______
Display program in HR Mini-web_____ Employee Mini-web_____ Both_____

Benefits: Please place a check mark next to the Benefits to be included and the # of plans. ______Medical – # of medical plans______

______Dental - # of dental plans______

______Vision - # of vision plans______

______Life/AD&D______

______Long Term Disability______

______Short Term Disability______

1. For each Medical Plan – Please answer the following questions
1. Name of Medical Carrier/Plan(s):

1.______

2.______

3.______
Covered Entities?

Employer Contribution / Employee Contribution
Employee / $ / $
Employee/Spouse / $ / $
Employee/Child / $ / $
Employee/Family / $ / $
Other: / $ / $
$ / $

2. Are Employees Allowed to Waive Coverage? Y or N

3. Choose a Rate Structure:
Tiered Rates______

If tiered, how many Tier Rate rows?______

Age Banded Rates______

If Age Banded:

Age Banded Table - # of Age-Band

Rows______Columns______

Dependent Table - # of Dependent

Rows______Columns______


2. For each Dental Plan – Please answer the following questions

1. Name of Dental Carrier/Plan(s):

1.______

2.______

2. Are Employees Allowed to Waive Coverage? Y or N

3. Covered Entities?

Employer Contribution / Employee Contribution
Employee / $ / $
Employee/Spouse / $ / $
Employee/Child / $ / $
Employee/Family / $ / $
Other: / $ / $
$ / $

3. For each Vision Plan – please answer the following questions

1. Name of Vision Carrier/Plan(s):

1.______

2.______

2. Are Employees Allowed to Waive Coverage? Y or N

3. Covered Entities?

Employer Contribution / Employee Contribution
Employee / $ / $
Employee/Spouse / $ / $
Employee/Child / $ / $
Employee/Family / $ / $
Other: / $ / $

4. Life – For your Life Plan - Please answer the following questions (If there is more than one Class (Executives, Managers etc) please answer the following questions per class)
1. Name of Life Carrier______

2. Life Plan: Times Earnings or Flat Amount (Circle One)

Class Description:______/______/______

a. Multiplier for Times Earnings (i.e. enter 2.0 for 2 x times earnings)

b. Rate (i.e. .56) ______

c. Maximum ______

3. Are Employees Allowed to Waive Coverage? Y or N

5. Long Term Disability Coverage – For your LTD coverage - Please answer the following questions (If there is more than one Class (Executives – Managers etc) please answer the following questions per class)

1. Name of LTD Carrier______

2. Class Description: ______/______/______

a. Percentage of Salary Covered (% (i.e. 60)______

b. Monthly Plan Max______

c. Rate per $100 (i.e. .56) ______
3. Are Employees Allowed to Waive Coverage? Y or N

6. Short Term Disability Coverage – For your STD coverage - Please answer the following questions

1. Name of STD Carrier______

a. Percent Covered (% (i.e. 60)______

b. Weekly Plan Maximum______

c. Rate (i.e. .56)______

2. Are Employees Allowed to Waive Coverage? Y or N

7. Flexible Spending Accounts – Please select the applicable FSA accounts

1._____Qualified Insurance Premium Plan
______

2._____Qualified Health Care Plan
______

3._____Qualified Dependent Care Plan
______

THIS SECTION IS FOR THE EMPLOYER TO FILL OUT

8. Vacation Criteria – Multiple Classes for vacation benefits are available. Please provide your Company’s vacation criteria.

1. Class Description (i.e. Employees less than 1 year, then the # of hours i.e. 40)

a. Class I______# of hours ______

b. Class II______# of hours______

c. Class III______# of hours______

9. Sick Pay Criteria – Multiple Classes for sick pay benefits are available. Please provide your Company’s sick pay criteria.

1. Class Description (i.e. Employees less than 1 year, then the # of hours i.e. 40)

a. Class I______# of hours ______

b. Class II______# of hours______

c. Class III______# of hours______

10. Holiday Schedule - Please provide a list of Holidays recognized by your company (i.e Thanksgiving and the day after)

1. ______

2. ______

3. ______

4. ______

5. ______

6. ______

7. ______

8. ______

9. ______

10. ______

11. ______

12. ______

11. Pension/401(k) – Multiple Class Descriptions are available. Please answer the following questions. (If only one pension criteria applies please provide the answers to 1a and 1b)

1. Class Description:______

a. Maximum employer matching percentage:______%

b. Percent matched: ______(ie 100%)

2. Class Description:______

a. Maximum employer matching percentage:______%

b. Percent Matched ______(ie 100%)

12. Bonus/Commission: - Bonus and Commission dollar amounts are entered by the Employee or HR Administrator. Enter an applicable description; then place a check mark in the appropriate Bonus and/or Commission questions:

Display description on benefit statement: Yes/No

Allow employee to enter annual bonus paid as a percentage of pre-tax annual salary: Yes/No

Allow the employee to enter pre-tax annual bonus dollar amount paid: Yes/No

Allow the employee to enter annual commission amount paid as percentage of pre-tax annual salary: Yes/No

Allow the employee to enter pre-tax annual commission dollar amount paid: Yes/No

13. Additional Benefits: Many additional benefits may be provided to employees that you may want to recognize, such as uniform allowances, coffee, etc.

1. Description of additional benefit______

a. Include benefit on statement?______(this means that the Benefit is a standard benefit for all employees and will automatically appear on the statement)

b. Employee Choice – YES or NO (means that the employee will be able to choose whether or not to include the benefit on the statement)

c. Annual benefit amount (per employee)______


2. Description of Additional benefit______

a. Include benefit on statement?______(this means that the Benefit is a standard benefit for all employees and you would like to include the benefit on the statement)

b. Employee Choice – YES or NO (means that the employee will be able to choose whether or not to include the benefit on the statement)
c. Annual benefit amount (per employee)______

3. Description of Additional benefit______,

a. Include benefit on statement?______(this means that the Benefit is a standard benefit for all employees and you would like to include the benefit on the statement)

b. Employee Choice – YES or NO (means that the employee will be able to choose whether or not to include the benefit on the statement)

c. Annual benefit amount (per employee)______

4. Description of Additional benefit______,

a. Include benefit on statement?______(this means that the Benefit is a standard benefit for all employees and you would like to include the benefit on the statement)

b. Employee Choice – YES or NO (means that the employee will be able to choose whether or not to include the benefit on the statement)

c. Annual benefit amount (per employee)______

14. Free Form Category – This section allows you to enter any other benefit provided by the Employer in Percents or Dollars and Cents on an annual, monthly or weekly basis. You can enter an unlimited number of Free Form Benefits:

1. Name of Benefit______

a. Benefit Value $______annual, monthly or weekly (circle one)

b. Employee Choice Yes/No (NO would indicate that everyone can enjoy this benefit and the Employee would not have to make a selection but could view the benefit, then choose Next button)

c. Computation Type – Percent or Dollars and Cents______

2. Name of Benefit______

a. Benefit Value $______annual, monthly or weekly (circle one)

b. Employee Choice Yes/No (NO would indicate that everyone can enjoy this benefit and the Employee would not have to make a selection but could view the benefit, then choose Next button)

c. Computation Type – Percent or Dollars and Cents______

15. Employer State Unemployment Tax – Please answer the following questions.

1. Name of State______

2. Unemployment Tax Rate______