Total Compensation Statement Worksheet The TCS Worksheet is designed to provide us with an overview of your benefit plans so we can create a customized list of data we need to complete your statements. Your contact information... Name* First Last Email* Phone*Company* About this project... What type of statements are you providing?* On-Demand Total Compensation Statements Custom Total Compensation Statements Number of Employees* Are you using the "annualized" or "actual dollars spent" method? Annualized Actual Dollars Spent Not sure yet What benefits costs will you be showing on the statements? Employer Costs Only Employer and Employee Costs Not sure yet What is your timeframe for completing the statements?* MM slash DD slash YYYY Your benefit programs... Medical Insurance... Do you offer medical insurance?* Yes, we offer medical insurance and share in the cost We offer medical insurance as a voluntary benefit (100% employee paid) We do not offer medical insurance What type of medical plans do you offer?(check all that apply) PPO POS HDHP HMO Other Do you have a wellness program that provides employees premium savings with participation?(lower medical rates with participation in biometrics screening, for example) Yes, our wellness program provides additional savings to employees with participation We offer a wellness program not tied to our medical plan We do not offer a wellness program With your HDHP plan, does the employer contribute to an HRA or HSA for employees? Yes No Dental Insurance... Do you offer dental insurance?* Yes, we offer dental insurance and share in the cost We offer dental insurance as a voluntary benefit (100% employee paid) We do not offer dental insurance Do you offer more than one dental plan? Yes No Vision Insurance...Do you offer vision insurance?* Yes, we offer vision insurance and share in the cost We offer vision insurance as a voluntary benefit (100% employee paid) Vision coverage is included as part of the medical plan We do not offer vision insurance Short-Term Disability...Do you offer Short-Term Disability (STD) Insurance?* Yes, we provide (or share in the cost) for short-term disability insurance We offer STD insurance as a voluntary benefit (100% employee paid) We do not offer STD insurance STD % of Income Covered 40% 50% 60% 66.67% 70% 100% Varies based on Employee Classification Our STD plan is self-insured STD Maximum Weekly Benefit $300 $500 $1,000 $1,250 $1,500 Varies based on Employee Classification We will get more details on your STD plan later. Long-Term Disability...Do you offer Long-Term Disability (LTD) Insurance?* Yes, we provide (or share in the cost) for long-term disability insurance We offer LTD insurance as a voluntary benefit (100% employee paid) We do not offer LTD insurance LTD % of Income Covered 40% 50% 60% 66.67% 70% Varies based on Employee Classification LTD Maximum Monthly Benefit $2,000 $3,000 $5,000 $10,000 $15,000 Varies based on Employee Classification We will get more details on your LTD plan later. Employer Provided Life Insurance... Do you provide Group Term Life Insurance?* Yes No Does your plan include an Accidental Death & Dismemberment (AD&D) clause? Yes No Is your life benefit a multiple of earnings or a flat dollar benefit?(multiple of earnings such as 1 times salary or a flat benefit such as $20,000 per employee) Multiple of Earnings Flat Dollar Benefit Flat Dollar Benefit per Employee $10,000 $15,000 $20,000 $25,000 $30,000 $50,000 Varies based on Employee Classification Multiple of Salary 1 times earnings 1.5 times earnings 2 times earnings 3 times earnings 4 times earnings Varies based on Employee Classification Maximum Life Benefit(maximum life insurance benefit)We will contact you later for the details of your Life Insurance plan. Retirement... Do you contribute towards a retirement plan?* Yes No Type of Retirement Plan(check all that apply) 401(k) 403(b) Profit Share RAP Pension (even if closed to new employees) SERP 457 plan ESOP Other Do you match funds?(check all that apply) Yes, we match funds No, we do not match funds We provide a contribution regardless of employee's participation Describe your company match...50% up to 6%, for example When are employees eligible to receive the match?(example, after six months of service or automatically enrolled) Include details of your retirement plan(s) below...(profit share, pension, SERP, ESOP, other) Statutory Benefits... Statutory benefits include Social Security and Medicare, Worker's Compensation Insurance and State and Federal Unemployment costs. Annual Worker Compensation Premium...(enter your annual Worker Compensation premium to evenly divide the total annual premium among all employees) State Unemployment Rate...(If you have more than one state rate, list with state and percent separated by comma. We will calculate the federal rate.) Regarding Statutory Benefits...If this information is not readily available, check here and we will send a reminder at a later date. I will provide Statutory benefits later Other Employer Provided Benefits... We will confine benefits that apply to a specific group (cell phone allowance, uniforms, bonuses, etc.) to statements of employees eligible for that benefit. Do you provide or contribute to any of the following?(check all that apply) Any other insurance plan not listed above (employer-paid, not voluntary) Bonuses or Other Incentive Compensation Cell Phone Allowance Car Allowance Uniforms Contribution to HSA, FSA, Etc. Employee Assistance Program Tuition Assistance / Continuing Education Other Other Employer Provided Benefits not Listed Above Voluntary or Additional Benefits... Do you offer any of the following voluntary benefits?(check all that apply) Employee Term Life Insurance Spouse Term Life Insurance Dependent Term Life Insurance Cancer Insurance Accident Insurance Hospital Insurance Critical Illness Intensive Care Insurance Long-Term Care Insurance Long-Term Disability Medical Flexible Spending Account Dependent Flexible Spending Account Health Savings Account Whole Life Insurance AD&D Insurance Other Other Voluntary Benefits not Listed Above Contact Phone Numbers & Websites... Do you want to include carrier phone numbers and websites on your statements? Yes, we will provide this information later No Next, submit and view additional options... best-antibiotics-otc.com