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Library: HR-Related Forms and Documents

Subset: Benefits

Subset: Total Compensation/Benefits Statement

Your Total Benefits and Compensation Statement

Dear______:

This benefit statement is a brief outline of the benefits, both cash and non-cash, provided to you as of (date). Should you have any questions regarding this report, please do not hesitate to contact ______.

Sincerely,

XXX

Title

Summary of Cash & Non-Cash Benefits

Non-Cash benefitEmployer Cost

FICA Tax$

Federal Unemployment$

State Unemployment$

Workers’ Compensation$

Medicare$

Medical Premium$

RxPrime Premium$

Dental Premium$

Vision Premium$

Life Insurance Premium$

Short-Term Disability Premium$

Long-Term Disability Premium$

401(k) Match$

Employer Paid Vacation$

Employer Paid Sick Time$

Employer Paid Holiday Time$

Total Employer Paid Benefits (non-cash)$

Annual Income (not including vacation pay)$

Actual Realized Income$

Note: The cost of providing these additional benefits equals an additional XXX% of your annual salary.

A = Annual Income,

B = Employer provided benefits

Medical Insurance

Medical benefits are paid up to the scheduled allowances found in your Group Medical Certificate Booklet. Please refer to this information.

Dental Expense Benefits

Dental care benefits are paid up to the scheduled allowances found in your Group Dental Plan Certificate Booklet. Please refer to this information.

Life and AD&D

______provides Group Life Insurance in an amount equal to $______. The face value of your Group Life Insurance and AD&D policy is $______.

In the event of your death, the face value of your Life and AD&D benefits will be paid to your beneficiary as follows:

Primary Beneficiary #1: ______

Short-Term Disability

Short-Term Disability benefits are provided to help offset loss of income in the event you become disabled. Benefits begin on _____ for a disability caused by an accident (non-work related), and on _____ for a disability caused by illness (non-work related). Benefits are paid for ______weeks. Your Short-Term Disability benefit is $_____ per week.

Long-Term Disability Insurance

Long-Term Disability benefits are provided as an additional source of income protection. This coverage will provide you a benefit of $______per month for ______days after the onset of your disability.

Retirement Plan

You can defer from %___ to %___ of your gross income. ______will match %_____ up to %_____ of your deferral.

Miscellaneous Benefits

Vacation ______

Paid Holidays ______

Sick Leave ______

Personal Days ______

The total value of your “time-off” benefits is $______

WHAT YOU SHOULD KNOW

ABOUT THIS BENEFIT REPORT

Your benefits contribute greatly to your total annual compensation and to your personal well being. The purpose of this report is to help you better understand the value of your benefit program. Every effort has been made to accurately communicate your benefits in this report. However, please note that errors do occasionally occur. If you should discover any discrepancies in this report, or if you need assistance in understanding its contents, please contact your supervisor or ______for further assistance.

This report is only a summary. The actual determination of your benefits is based solely on the plan documents provided by each carrier of the plan. This summary is not legally binding, and it does not alter or amend any original plan documents. We hope this report will be helpful to you and your family in planning for your financial security.

GENERAL ASSUMPTIONS: The nature of a benefit report requires certain assumptions to be made. It assumes, for example, that your income and benefits will remain unchanged until retirement. It also assumes that the law will remain unchanged until you retire.

HRSentry