2012-09-26 CC Packet - Laserfiche WebLink

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(9) FMLAMATTERs (A FMLA Plan Information • mber of Employees: Number of Employees Currently on FMLA Leave (Additional Fees Apply): Nu ser of Company Locations: State Abbreviation and Corresponding Company Location Code: Eligibil '1 to be determined by TASC? ❑ Yes ❑ No (Please note that determination of eligibility by TASC may incur additional costs.) Will your LA run concurrent with your workers compensation and short-term disability plans? ❑ Yes ❑ No Will you be - nually reporting FMLA hours used or providing an hour data feed? ❑ Manual ❑ Data Feed FMLA 12 -mont Tracking Type (e.g., rolling, calendar, etc.): (B) Plan Start Date: FMLAMatters Admin. Only Special Instructions • (10) ERISAEDGE (A) Plan Design The following benefits are subject to ERISA. Plea - complete each column as it relates to all benefits offered by the Employer. Column A: List of applicable health & welfare benefit- ubject to ERISA - Indicate by completing all columns B -1 for benefits offered by Employer. Column B: Contract Year - For each applicable benefit off- ed, enter the ACTUAL Contract Year of the policy with each carrier. Example: Health- Contract Year is January 1- renews each Ja ary 1. Column C: Benefits Covered Under Group Insurance (Y /N) - en -r Yes if covered under Group Insurance Policy - N if not. Column D: Pre -Tax Benefit Y/N - For all applicable Employer bene s offered; are the employees allowed to pre -tax their contributions under your Section 125 Plan, Y /N. Column E: Benefit Renewal Period - Typically will be same as Contract r- ewal unless the benefit renews, other than on the Contract Policy Year with carrier. Example: For Health- Contract Year with carrier is March 1- Febru • 28 but the benefit is a Calendar year deductible year. In this example, for health in Column 8 the Contract Year will be March 1 and Column E will be Ja • uary 1. (A) (B) (C) (D) _.. (E) ( (G) (H) (I) Contract Benefits Pre -Tax Benefit Carrier N. • e Employer Paid? Funding Total Number Year Covered Benefit Renewal Employee Paid? Arrangement of Participants Under Group (Y /N) Period Or Both? Sl - Self - Insured (not including Ins. (Y /N) I Fl- Fully- Insured Dependents•) EX- Experience Rated �— - � Health Dental Vision Life I i STD LTD Severance : 11:1 1 Ins. Policy Wellness or + EAP Stop Loss - -- - - -- �------ ----- - - - --- Insurance Voluntary I { - - - -- -- - --- - - - -- - Products TC -3923- 080111 Employer Initial ' '`TASC 21