Payroll 210 Badge #06 - Federal and State Tax Reporting-Payroll 210 Badge #6

Payroll 210 Badge #6 - Handout #5

Pdf Summary

This document is an Employee Benefit Election Form for employees receiving Workers’ Compensation time-loss benefits from the employer’s Workers’ Compensation Trust. It explains that an employee may choose to supplement their time-loss income by using available sick leave and/or vacation leave. For any given day, the total combined sick and vacation hours used cannot exceed the number of hours the employee is regularly scheduled to work.<br /><br />The form warns that how an employee uses (or exhausts) leave may affect eligibility for employer-sponsored health care benefits and retirement contributions, and encourages the employee to contact the Payroll department to review options before using all available leave.<br /><br />The employee must select one of the following options for each day they are paid time-loss benefits (Sunday through Saturday):<br />1) Use a specified number of sick leave hours per day (up to scheduled work hours);<br />2) Use a specified number of vacation leave hours per day (up to scheduled work hours); or<br />3) Elect not to use any sick or vacation leave to supplement time-loss benefits during the disability period.<br /><br />By signing, the employee acknowledges that their election may impact future medical benefits and that they are responsible for contacting Payroll to understand those impacts. The employee also acknowledges they may change their election later, with changes effective from the date of the change forward. Additionally, the employee is responsible for contacting the Department of Retirement Systems to determine whether exhausting leave will affect retirement benefits.<br /><br />The form includes fields for employee name, position, signature, and date and is labeled as a sample.

Keywords

Employee Benefit Election Form

Workers’ Compensation time-loss benefits

Workers’ Compensation Trust

supplemental income using leave

sick leave hours election

vacation leave hours election

scheduled work hours limit

payroll department consultation

health care benefits eligibility impact

retirement contributions and Department of Retirement Systems