Your Personalized Total Rewards Statement Made Especially For: <<First Name>> <<Last Name>> <<Street Address>> <<City>>, <<State>> <<Zip>> 2022 T <Company Name> Contribution Your Contribution Direct Compensation Calendar Year 2022 Salary <<CY2022S>> N/A Health and Welfare Bene its Medical <<MEDCO>> <<EEMED>> Dental <<DENCO>> <<EEDEN>> Vision <<VISCO>> <<EEVIS>> Health Savings Account <<HSACO>> <<EEHSA>> Life/AD&D and Disability Basic Life and AD&D 2.5 x Salary <<LADD>> N/A Voluntary Life N/A <<EELIFE>> Spouse Life N/A <<SPLIFE>> Child Life N/A <<CHLIFE>> Short-Term Disability (STD) <<STD>> N/A Long-Term Disability (LTD) <<LTD>> N/A Saving and Retirement Bene its 401(k) <<ER401k>> <<EE401k>> Social Security and Medicare <<SSMCRE>> <<EESSMCRE>> Other Programs Flexible Spending Accounts (FSAs) N/A <<EEFSA>> Paid Time O * Sick Days <<SICK>> days N/A Vacation Days <<VAC>> days N/A Holiday <<HOL>> days N/A TOTAL VALUE <<TOT>> <<EETOT>> This statement is designed to provide a brief overview of bene its. This statement does not constitute a Summary Plan Description nor a modi ication of the Plan terms and conditions; the Plan Document provisions shall control and govern in the event of any discrepancy. Dear <<First Name>>: We are pleased to provide you with this personalized statement of your earnings and bene its for 2022. It is our sincere hope that the protection and security of these bene its will make life better for you today as well as provide you with a more secure future. The enclosed 2022 Total Rewards Statement was prepared just for you. It includes a brief summary of your bene its, but also provides “costs of bene its” information, which is important when considering your total compensation. More importantly, this statement re lects information about you — about your earnings, your bene it choices and your future. And, as some of these bene its are based on your earnings and length of service with our company, their value will grow as your earnings and service years increase. We are constantly working to provide you with a bene it package that is competitive and progressive within our industry and our community. We greatly appreciate your continued service and dedication to the company. If you have any questions after reviewing your Total Rewards Statement, please contact <Contact Name> at XXX XXX XXXX. Sincerely, <CEO Name> <Title> <Company Name> *<Company Name> provides employees with time away from work for vacations, holidays, sick and personal days. Time away amounts are prorated based on start date and full-time equivalent (FTE), in accordance with the calendar year (January 1 – December 31). Note that some employees are not eligible to participate in <Company Name>’s Time Away program. Per sona l and Con i dent i a l
This statement re ects employer-sponsored programs and voluntary plans. The annual costs of your employer-sponsored bene ts are ongoing amounts paid for you to participate in the plans. Where actual dollars paid in bene ts are not readily available (e.g., medical claims) the average employer costs to provide coverage are used. These costs include plan administration, actual claims, and premiums. Every e ort has been made to provide you with accurate information in this statement. However, there is always the possibility of error(s) occurring in the collection and/or calculation of data. The general descriptions of the bene ts in this statement are abbreviated and are for reference purposes only. The amounts shown re ect estimates and your actual bene ts may vary. The amount and availability of all bene ts will be determined in accordance with the current provisions of the of cial plan documents, which govern in all cases. The company reserves the right to change the bene t plans at any time, with or without advance notice, for any reason. Revised provisions may supersede, modify, or eliminate existing plan(s). Plan provisions and eligibility for bene ts do not constitute an employment contract (legal document or other) and are not intended to represent a guarantee of employment or bene ts, expressed or implied. Annual Pay For the purpose of this bene ts statement, <Company Name> de nes annual pay as the gross compensation paid to you on an annual basis. The retirement bene t information represented is based on your gross annual compensation. Bene t costs are based on the 2022 calendar year rates. Pay and <Company Name>’s costs for your bene ts have been annualized for employees with less than one year of service as of January 2022. Bene ciary Designations Your applicable bene ciary designation(s) are not re ected in this statement; however, it is important that you periodically review such information. If your family status changes, you may wish to change your bene ciary designation(s). If so, you may update this information online or the necessary forms may be obtained from Human Resources and our bene it plan carriers. Medical <Company Name>’s health insurance provider is <Carrier Name>. The current medical plan option is <<EEMEDPLAN>> medical plan with a Health Savings Account (HSA). You are enrolled in this medical plan with <<COVLVL>> coverage. The <<EEMEDPLAN>> medical plan o ers the following plan design under its Tier 1 Provider Network: • Deductible: $X,XXX individual/$X,XXX other coverage levels • Out-of-Pocket Maximum: $X,XXX individual/$X,XXX other coverage levels • Co-Insurance: <Company Name> pays XX%, You pay XX% • Of ce Visit Copay: $XX primary care/$XX specialist • Urgent Care Copay: $XX • ER Copay: deductible, then coinsurance • Prescription copay: $XX generic/$XX preferred brand/ $XX non-preferred brand • Preventive care covered at 100% before deductible Healthy Savings Account (HSA) A health savings account (HSA) is a tax-free savings account speci ically for health-related expenses. Put simply, it is a way for you to reserve funds for medical expenses without paying taxes or interest on those dollars. The funds you contribute to your HSA go directly into your bank account before they are taxed making them pre-tax earnings. An HSA is an easy way to make your dollars go further when it comes to medical expenses. <Company Name>’s HSA administrator is <HSAADMIN>. Flexible Spending Accounts <Company Name> o ers Flexible Spending Accounts (FSA) through <FSA Provider>. This plan allows you to make pretax contributions for your unreimbursed healthcare expenses up to $X,XXX per year and/or employment-related dependent daycare expenses up to $X,XXX per year. You elected to contribute $<<MEDFSA>> to the Medical FSA and $<<DCFSA>> to the Dependent DayCare FSA. If you are currently participating in a FSA and wish to participate in the next plan year, you must re-enroll during the annual open enrollment. Vision <Company Name>’s vision insurance provider is <Vision Carrier>. There are two vision options, the <Vision Carrier> Standard and the <Vision Carrier> Preferred plan. The <Vision Carrier> Standard plan o ers the following plan design: • Frames and Contacts: $130 allowance + 20% discount on balance • Exam copay: $10 • Additional discounts are available for a second pair of frames when using <Vision Carrier> Providers The <Vision Carrier> plan o ers the following plan design: • Frame and Contacts: $XXX allowance + 20% discount on balance • Exam Copay: $0 • Additional discounts on lens options and for a second pair of frames when using <Vision Carrier> Providers Dental <Company Name>’s dental insurance provider is <Dental Carrier>. There are two dental options, the <Option 1> plan and the PPO plan. The <Option 1> plan o ers the following plan design: • Annual Deductible: $XX individual/no limit on other coverage levels • Annual Maximum Bene it: $X,XXX per person • Preventive Services (exams, cleanings, x-rays): XX% paid • Basic Services ( illings): XX% paid • Major Services (bridges, dentures): XX% paid • Orthodontia (on eligible children): $X,XXX lifetime maximum The PPO plan o ers the following plan design: • Annual Deductible: $XX individual/$XX other coverage levels • Annual Maximum Bene it: $X,XXX per person • Preventive Services (exams, cleanings, x-rays): 100% paid • Basic Services ( illings): XX% paid • Major Services (bridges, dentures): XX% paid • Orthodontia (on eligible children): $X,XXX lifetime maximum <Company Name> provides you with group life insurance in the amount of 2.5x your annual earnings up to a maximum of $XXX,XXX,XXX. In addition, <Company Name> provides 1.5x salary up to $XXX,XXX accidental death and dismemberment insurance. Voluntary Life Insurance <Company Name> o ers voluntary life insurance coverage, you are eligible to purchase anywhere from 1 to 4 times your annual salary, up to a $XXX,XXXX maximum. You have elected the following amounts: Employee $ <<EELIFE>> In addition, you can choose to elect dependent life insurance for spouse and/or eligible children at a at monthly rate. You have elected the following amounts: Spouse $ <<SPLIFE>> Children $ <<CHLIFE>> Short-Term and Long-TermDisability <Company Name> provides all full-time employees with short-term and longterm disability insurance through <Carrier Name>. If you are unable to work due to an illness or injury, after a XX-day waiting period you are eligible to receive XX% of pre-disability earnings (this bene it is non-taxable when paid). <Company Name> 401(k) Plan <Company Name> o ers you a retirement plan through <Carrier Name> and provides 100% matching contributions on your irst X% of contributions after meeting the eligibility requirements. Tuition Reimbursement Program Full-time employees are eligible for $X,XXX in tuition reimbursement per year, and part-time employees are eligible for $X,XXX in tuition reimbursement per year. Additional Bene its In addition to the bene ts described in this statement, as well as those that are legally mandated, the following bene ts are o ered: • HR Services • Payroll Processing • IT Support • Of ce Space • Support Sta • Family Medical Leave • Company Cell Phone • Adoption Assistance — You can receive up to $X,XXX per adopted child, up to a lifetime maximum of $X,XXX. • <Company Name> Fitness Center Discounts • <Early Education Program> national provider of early education and preschools, employer-sponsored childcare, back-up care and other work/life solutions General Information RESOURCE PHONE WEBSITE/E MAIL Medical Carrier Contact XXX XXX XXXX <Email Address> Dental Carrier Contact XXX XXX XXXX <Email Address> Vision Carrier Contact XXX XXX XXXX <Email Address> HIA Contact XXX XXX XXXX <Email Address> FSA Contact XXX XXX XXXX <Email Address> Life and AD&D Contact XXX XXX XXXX <Email Address> Retirement Contact XXX XXX XXXX <Email Address> Human Resources Contact XXX XXX XXXX <Email Address> HEALTH AND WELLNESS LIFE AND DISABILITY RETIREMENT ADDITIONAL BENEFITS Your Personalized Total Rewards Statement Made Especially For: <<First Name>> <<Last Name>> 2022 Per sona l and Con i dent i a l
RkJQdWJsaXNoZXIy NjU3MjAy