EBS Survey – Questionnaire – WhitneySmith Company

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Page 1

1. Participant Data

Organization

Your Name

Your Job Title

Phone Number

Fax Number

Email Address

Organization’s Address

City

Zip Code

Which of the following best describes the function of your organization?

Please describe the function of your organization.

How many years has your business been in operation?

Number of full-time employees as of January 1, 2023:

Number of part-time employees as of January 1, 2023:

2. Paid Time Off

Do you provide a paid time off (PTO) plan that combines vacation with other types of leave (e.g. sick leave, personal days, etc.)?

YesNo

Please describe the other types of leave that are combined with vacation.

Is an employee’s PTO allotment determined by years of service?

YesNo

How many PTO days does an employee receive each year?

Part-time	Full-time	Management	Executives

How many PTO days does an employee receive each year based on their length of service?

	Part-time	Full-time	Management	Executives
6 months of service
1 year
2 year
3 years
4 years
5 years
10 years
15 years
20 years
30+ years

How do employees earn PTO?

Accrued on a periodic basis (e.g., hourly, weekly, etc.)Granted annually (anniversary date, calendar year, etc.)

Employees may begin using PTO after how many months of service? (Please enter 0 if employees are immediately eligible)

May unused PTO be carried over from year to year?

YesNo

How many PTO days may employees carry over per year?

How many total carryover days may employees accumulate? To a maximum of:

May employees sell back or get paid for PTO in lieu of using it?

YesNo

How many PTO days may employees sell back per year?

At what value of compensation are the days sold back? (as a percentage, e.g. 80% compensation)

May employees purchase extra PTO?

YesNo

What is your policy for purchasing extra PTO?

3. Vacation

Do you provide paid vacation separate from other paid-time-off plans?

YesNo

Is an employee’s vacation day allotment determined by years of service?

YesNo

How many vacation days does an employee receive each year?

Part-time	Full-time	Management	Executives

How many vacation days does an employee receive each year based on their length of service?

	Part-time	Full-time	Management	Executives
6 months of service
1 year
2 year
3 years
4 years
5 years
10 years
15 years
20 years
30+ years

How do employees earn vacation?

Accrued on a periodic basis (e.g., hourly, weekly, etc.)Granted annually (anniversary date, calendar year, etc.)

Employees may begin using vacation days after how many months of service? (Please enter 0 if employees are immediately eligible)

May unused vacation be carried over from year to year?

YesNo

How many vacation days may employees carry over per year?

How many total carryover days may employees accumulate? To a maximum of:

May employees sell back or get paid for vacation in lieu of using it?

YesNo

How many vacation days may employees sell back per year?

At what value of compensation are the days sold back? (as a percentage, e.g. 80% compensation)

May employees purchase extra vacation?

YesNo

What is your policy for purchasing vacation days?

4. Sick leave

Do you provide paid sick leave separate from other paid-time-off plans?

YesNo

Is an employee’s sick day allotment determined by years of service?

YesNo

How many sick days does an employee receive each year?

Part-time	Full-time	Management	Executives

How many sick days does an employee receive each year based on their length of service?

	Part-time	Full-time	Management	Executives
6 months of service
1 year
5 years
10+ years

How do employees earn sick leave?

Accrued on periodic basis (e.g., hourly, weekly, etc.)Granted annually (anniversary date, calendar year, etc.)

Employees may begin using sick leave after how many months of service? (Please enter 0 if employees are immediately eligible)

May unused sick leave be carried over from year to year?

YesNo

How many sick leave days may employees carry over per year?

How many total carryover days may employees accumulate? To a maximum of:

May employees sell back or get paid for sick leave in lieu of using it?

YesNo

How many sick leave days may employees sell back per year?

At what value of compensation are the days sold back? (as a percentage, e.g. 80% compensation)

Employees may also use sick leave for:

Care for child with an illness or injuryCare for spouse with an illness or injury Care for parent with an illness or injuryCare for newborn, adopted or foster childQualifying exigency under FMLAService member leave

Can employees donate sick days to other employees?

YesNo

How many sick days can one employee donate to other employees per year?

How many sick days can one employee receive as donated sick leave from other employees per year?

5. Extended Illness Account

Do you offer a separate paid time off account for extended illness (sometimes referred to as a Sick Bank or Medical Reserve Account)?

YesNo

How do employees accumulate time in this account?

Unused paid time off days are put into accountOther

How do employees accumulate time?

What is the maximum number of days per year that an employee may have added to this account?

How many total days may an employee accumulate in this account?

6. Holidays

Do you provide paid holidays separate from other paid-time-off plans?

YesNo

Employees are eligible for holidays after how many months of service? (Please enter 0 if employees are immediately eligible)

How many paid holidays do you provide for employees each year?

	Part-time	Full-time	Management	Executives
Scheduled or Fixed Holidays
Floating Holidays

Page 2

7. Personal Days

Do you provide paid personal days separate from other paid-time-off plans?

YesNo

Are paid personal days allocated based on length of service with the company?

YesNo

Number of personal days provided to employees

Part-time

Full-time

Management

Executives

How many personal days does an employee receive each year based on their length of service?

	Part-time	Full-time	Management	Executives
6 months of service
1 year
5 years
10 years
15 years
20+ years

How are personal days earned?

Accrued on a periodic basis (e.g., hourly, weekly, etc.)Granted annually (anniversary date, calendar year, etc.)

Employees may begin using personal days after how many months of service? (Please enter 0 if employees are immediately eligible)

May unused personal days be carried over from year to year?

YesNo

How many personal days may employees carry over per year?

How many total days may employees accumulate with carry over?

May employees sell back or get paid for personal days in lieu of using them?

YesNo

How many personal days may employees sell back per year?

At what value of compensation are the days sold back? (as a percentage, e.g. 80% compensation)

8. Other Paid Absences

How many days of paid time off do you provide employees for the following absences?

	Part-time	Full-time	Management	Executives
Bereavement for Immediate Family
Bereavement for Other Relatives or Close Friends
Jury Duty
Military Duty
Wedding and/or Honeymoon
Birthday (if not included in personal days)

9. Medical Leaves of Absence (FMLA and Parental)

Family and Medical Leave

Is your organization covered by the Family and Medical Leave Act (employers with 50 or more employees within a 75-mile radius)?

YesNo

Do you allow employees to use available paid time off (PTO, sick leave, vacation time) during the leave of absence?

YesNo

Please mark all that apply.

Employee’s Own Medical Care

Yes, can use paid time off accountsNo, cannot use paid time off accounts

Children’s Medical Care

Yes, can use paid time off accountsNo, cannot use paid time off accounts

Parents’ Medical Care

Yes, can use paid time off accountsNo, cannot use paid time off accounts

Does your organization provide time off in addition to the FMLA-required 12 weeks?

YesNo

How many more weeks of paid or unpaid time does your organization provide in addition to the 12 weeks required by the FMLA?

	Unpaid	Paid
Employee’s Own Medical Care
Children’s Medical Care
Parents’ Medical Care

Parental Leave (NOTE: THIS SUBSECTION IS NEW)

Does your organization have a formal parental leave policy?

YesNo

Does parental leave run concurrently with FMLA leave?

YesNo

How many weeks of paid or unpaid leave does your organization provide for the following reasons?

	Unpaid	Paid
Birthing (pregnancy/birth)
Bonding (includes adoption and foster care)

10. Personal/Educational Leaves of Absence

How many weeks of paid (not including the previously reported types of paid absences) or unpaid leave does your organization offer employees for the following reasons?

	Unpaid	Paid
Personal
Educational

11. Medical Benefits

Do you offer medical benefits to your employees?

YesNo

Are there eligibility requirements employees must meet to qualify for medical benefits?

YesNo

Part-time (P-T) Benefit Eligibility

Part-time employees are eligible for medical benefits

Hours per week required

Length of service required (in days)

Full-time (F-T) Benefit Eligibility

Full-time employees are eligible for medical benefits

Hours per week required

Length of service required (in days)

How many medical plans do you offer to employees?

Which of the following medical plans are offered to employees? Check all that apply.

Traditional Indemnity

SEPARATOR- Traditional Indemnity

Who is eligible?

Part-time employeesFull-time employees

% of Eligible Employees Participating

Annual Cost Per Employee (Annual Cost per Employee = Total plan cost before employee contributions divided by total covered employees)

Deductible Information

	Deductible (Individual)	Deductible (Family)	Benefits %
In-Network
Out-of-Network

Doctor’s Office Copay

Prescription Drug Card Copay

Generic

Brand

Non-Formulary

Preferred Provider (PPO)

SEPARATOR- PPO

Who is eligible?

Part-time employeesFull-time employees

% of Eligible Employees Participating

Annual Cost Per Employee (Annual Cost per Employee = Total plan cost before employee contributions divided by total covered employees)

Deductible Information

	Deductible (Individual)	Deductible (Family)	Benefits %
In-Network
Out-of-Network

Doctor’s Office Copay

Prescription Drug Card Copay

Generic

Brand

Non-Formulary

Point of Service (POS)

SEPARATOR- POS

Who is eligible?

Part-time employeesFull-time employees

% of Eligible Employees Participating

Annual Cost Per Employee (Annual Cost per Employee = Total plan cost before employee contributions divided by total covered employees)

Deductible Information

	Deductible (Individual)	Deductible (Family)	Benefits %
In-Network
Out-of-Network

Doctor’s Office Copay

Prescription Drug Card Copay

Generic

Brand

Non-Formulary

Health Maintenance (HMO)

SEPARATOR- HMO

Who is eligible?

Part-time employeesFull-time employees

% of Eligible Employees Participating

Annual Cost Per Employee (Annual Cost per Employee = Total plan cost before employee contributions divided by total covered employees)

Deductible Information

	Deductible (Individual)	Deductible (Family)	Benefits %
In-Network
Out-of-Network

Doctor’s Office Copay

Prescription Drug Card Copay

Generic

Brand

Non-Formulary

Health Savings Account (HSA)

SEPARATOR- HSA

Who is eligible?

Part-time employeesFull-time employees

% of Eligible Employees Participating

Annual Cost Per Employee (Annual Cost per Employee = Total plan cost before employee contributions divided by total covered employees)

Deductible Information

	Deductible (Individual)	Deductible (Family)	Benefits %
In-Network
Out-of-Network

Doctor’s Office Copay

Prescription Drug Card Copay

Generic

Brand

Non-Formulary

Exclusive Provider (EPO)

SEPARATOR- EPO

Who is eligible?

Part-time employeesFull-time employees

% of Eligible Employees Participating

Annual Cost Per Employee (Annual Cost per Employee = Total plan cost before employee contributions divided by total covered employees)

Deductible Information

	Deductible (Individual)	Deductible (Family)	Benefits %
In-Network
Out-of-Network

Doctor’s Office Copay

Prescription Drug Card Copay

Generic

Brand

Non-Formulary

For HSA plans, does the employer provide contributions?

YesNo

At what level?

How are your medical benefits plans funded? Select all that apply.

Fully InsuredMinimum Premium Self-Funded PlanSelf-Funded Plan with Reinsurance

Minimum Premium Self-Funded Plan

What is the employer’s maximum $ liability for an individual (specific) claim?

What is the plan’s maximum lifetime $ liability for an individual?

Who provides the administrative and claims paying services for the plan?

Insurance CompanyIndependent Third Party Administrator

Self-Funded Plan with Reinsurance

What is the employer’s maximum $ liability for an individual (specific) claim?

What is the plan’s maximum lifetime $ liability for an individual?

Who provides the administrative and claims paying services for the plan?

Insurance CompanyIndependent Third Party Administrator

What is your primary (highest enrollment) medical plan?

What cost-sharing option do you use for employee and dependent coverage in this plan?

Two-tier (Employee, EE + Family)Three-tier (Employee, EE+1, EE+2, or more)Four-tier (Employee, EE+Spouse, EE+Child, EE+Family)

What are the gross monthly premiums charged to the employer for your primary and secondary medical plans and what are the cost sharing percentages of the gross monthly premiums paid by the employee? (i.e. EE monthly payroll deduction divided by gross monthly premium at each covered level)

Coverage Level: Employee Only

Primary Plan Gross Monthly Premium

	Part-time	Full-time	Exec
% Paid by Employee

Secondary Plan Gross Monthly Premium

	Part-time	Full-time	Exec
% Paid by Employee

Coverage Level: EE + 1 or EE + Spouse

Primary Plan Gross Monthly Premium

	Part-time	Full-time	Exec
% Paid by Employee

Secondary Plan Gross Monthly Premium

	Part-time	Full-time	Exec
% Paid by Employee

Coverage Level: EE + Child

Primary Plan Gross Monthly Premium

	Part-time	Full-time	Exec
% Paid by Employee

Secondary Plan Gross Monthly Premium

	Part-time	Full-time	Exec
% Paid by Employee

Coverage Level: EE + 2 or more or EE + Family

Primary Plan Gross Monthly Premium

	Part-time	Full-time	Exec
% Paid by Employee

Secondary Plan Gross Monthly Premium

	Part-time	Full-time	Exec
% Paid by Employee

Have you taken or do you plan to take steps to reduce employer cost?

YesNo

What steps have you taken or do you plan to take?

	In last 2 plan years	In next plan year
Increase plan copay amounts
Increase employee share of cost
Increase plan deductible
Reduce plan coinsurance benefit %
Change plan to PPO network design
Implement POS plan
Modify retiree coverage
Change insurance company
Modify benefits
Implement HMO plan
Implement wellness program
Implement consumer driven health plan with HSA
Change from fully- to self-insured plan
Discontinue employee health insurance benefit plans
Implement health reimbursement account (HRA)
Add Section 125 cafeteria plan pre-tax benefit

12. Dental Benefits

Do you offer dental benefits to your employees?

YesNo

What are the eligibility requirements for dental benefits?

Part-time (P-T) Benefit Eligibility

Part-time employees are eligible for dental benefits

Hours per week required

Length of service required (in days)

Full-time (F-T) Benefit Eligibility

Full-time employees are eligible for dental benefits

Hours per week required

Length of service required (in days)

How many dental plan options do you offer to employees?

Which of the following dental plans are offered to employees? Check all that apply.

Traditional Indemnity

SEPARATOR- Traditional Dental Indemnity

Who is eligible?

Part-time employeesFull-time employees

% of Eligible Employees Participating

Annual Cost Per Employee (Annual Cost per Employee = Total plan cost before employee contributions divided by total covered employees)

Preferred Provider (PPO)

SEPARATOR- Dental PPO

Who is eligible?

Part-time employeesFull-time employees

% of Eligible Employees Participating

Annual Cost Per Employee (Annual Cost per Employee = Total plan cost before employee contributions divided by total covered employees)

Dental Maintenance (DMO)

SEPARATOR- DMO

Who is eligible?

Part-time employeesFull-time employees

% of Eligible Employees Participating

Annual Cost Per Employee (Annual Cost per Employee = Total plan cost before employee contributions divided by total covered employees)

Voluntary Pre-Paid Plan

SEPARATOR- Vol Pre Paid

Who is eligible?

Part-time employeesFull-time employees

% of Eligible Employees Participating

Annual Cost Per Employee (Annual Cost per Employee = Total plan cost before employee contributions divided by total covered employees)

Other Dental Plan

SEPARATOR- Other Dental

Who is eligible?

Part-time employeesFull-time employees

% of Eligible Employees Participating

Annual Cost Per Employee (Annual Cost per Employee = Total plan cost before employee contributions divided by total covered employees)

What is your primary (highest enrollment) dental plan?

Primary Dental Plan Features

	Deductible $	Benefits %
Preventative
Basic
Major
Orthodontia

Maximum Benefit

$ per year (preventative, basic and major)

$ lifetime (orthodontia)

What cost-sharing option do you use for employee and dependent coverage in your primary dental plan?

Two-tier (Employee, EE + Family)Three-tier (Employee, EE+1, EE+2, or more)Four-tier (Employee, EE+Spouse, EE+Child, EE+Family)

What are the gross monthly premiums, charged to the employer, for your primary dental plan and what are the cost sharing percentages of the gross monthly premiums paid by the employee (i.e. EE monthly payroll deduction divided by gross monthly premium at each covered level)?

Employee Only

Gross Monthly (Billed) Premium per Employee

% Paid By Employee

Part-Time

Full-Time

Exec

EE + 1 or EE + Spouse

Gross Monthly (Billed) Premium per Employee

% Paid By Employee

Part-Time

Full-Time

Exec

EE + Child

Gross Monthly (Billed) Premium per Employee

% Paid By Employee

Part-Time

Full-Time

Exec

EE + 2 or more or EE + Family

Gross Monthly (Billed) Premium per Employee

% Paid By Employee

Part-Time

Full-Time

Exec

Page 3

13. Vision Care Benefits

Do you offer vision care benefits to your employees?

YesNo

Are there eligibility requirements employees must meet to qualify for vision care benefits?

YesNo

Part-time (P-T) Benefit Eligibility

Part-time employees are eligible for vision benefits

Hours per week required

Length of service required (in days)

Full-time (F-T) Benefit Eligibility

Full-time employees are eligible for vision benefits

Hours per week required

Length of service required (in days)

Vision Benefits Features

Which of the following are included in your vision care benefits? Check all that apply.

Routine CareFramesLensesContact Lenses

Routine Care

Frequency of Benefit

Copay

% Discount

Allowance

Frames

Frequency of Benefit

Copay

% Discount

Allowance

Lenses

Frequency of Benefit

Copay

% Discount

Allowance

Contact Lenses

Frequency of Benefit

Copay

% Discount

Allowance

Which cost sharing do you use for employee and dependent coverage in your vision care plan?

Two tier (Employee, EE + Family)Three tier (Employee, EE+1, EE+2 or more)Four tier (Employee, EE+Spouse, EE+Child, EE+Family)

What are the gross monthly premiums, charged to the employer, for your primary vision plan and what are the cost sharing percentages of the gross monthly premiums paid by the employee? (i.e. EE monthly payroll deduction divided by gross monthly premium at each coverage level)

Coverage Level: Employee Only

Gross Monthly (Billed) Premium per Employee $

% Paid By Employee

Part-Time

Full-Time

Exec

Coverage Level: EE + 1 or EE + Spouse

Gross Monthly (Billed) Premium per Employee $

% Paid By Employee

Part-Time

Full-Time

Exec

Coverage Level: EE + Child

Gross Monthly (Billed) Premium per Employee $

% Paid By Employee

Part-Time

Full-Time

Exec

Coverage Level: EE + 2 or more or EE + Family

Gross Monthly (Billed) Premium per Employee $

% Paid By Employee

Part-Time

Full-Time

Exec

14. Disability Benefits

Do you offer disability benefits to your employees?

YesNo

Are there eligibility requirements employees must meet to qualify for disability benefits?

YesNo

Part-time (P-T) Eligibility

Part-time employees are eligible for disability benefits

Hours per week required

Length of service required (in days)

Full-time (F-T) Eligibility

Full-time employees are eligible for disability benefits

Hours per week required

Length of service required (in days)

Please indicate which types of disability insurance are available to the following groups of employees.

Short-term Disability

% Premium Paid by Employee (Part-time)

% Premium Paid by Employee (Full-time)

% Premium Paid by Employee (Exec)

What type of premium is billed by carrier?

CompositeAge Band Ratings

What is the rate?

What benefits are provided under this plan for the majority of your eligible employees?

Elimination Period (in days)

Percentage (%) of Earnings

Maximum Benefit ($ per week)

Max Benefit Period (in weeks)

Long-term Disability

% Premium Paid by Employee (Part-time)

% Premium Paid by Employee (Full-time)

% Premium Paid by Employee (Exec)

What type of premium is billed by carrier?

CompositeAge Band Ratings

What is the rate?

What benefits are provided under this plan for the majority of your eligible employees?

Elimination Period (in days)

Percentage (%) of Earnings

Maximum Benefit ($ per month)

Max Benefit Period (in weeks)

If you include an “own occupation” definition of disability in the long-term disability plan for the majority of your eligible employees, does the “own occupation” definition apply for:

Up to age 65/70A limited number of years

How many years?

Long-term Care

% Premium Paid by Employee (Part-time)

% Premium Paid by Employee (Full-time)

% Premium Paid by Employee (Exec)

What type of premium is billed by carrier?

CompositeAge Band Ratings

What is the rate?

What benefits are provided under this plan for the majority of your eligible employees?

Elimination Period (in days)

Percentage (%) of Earnings

Maximum Benefit ($ per month)

Max Benefit Period (in months)

15. Life Insurance

Do you offer employer-paid life insurance to your employees?

YesNo

Are there eligibility requirements for life insurance benefits?

YesNo

Part-time (P-T) Eligibility

Part-time employees are eligible for life insurance

Hours per week required

Length of service required (in days)

Full-time (F-T) Eligibility

Full-time employees are eligible for life insurance

Hours per week required

Length of service required (in days)

What is the life insurance benefit for the following groups of employees (e.g. $10,000 per employee, 2x salary, etc.)?

Part-time

Full-time Hourly

Full-time Salaried

Management

Executives

How is the maximum benefit measured? Select all that apply.

Dollars (e.g., up to $100,000)Salary (e.g., up to 5x salary)

What is the maximum benefit in dollars?

If the life insurance benefit is a multiple of an employee’s salary, is there a maximum benefit?

Yes

What is the maximum benefit?

What options do employees have to purchase additional life insurance? Select all that apply.

Additional coverage on employeeCoverage for spouse and childrenNone

What type of premium is billed by the carrier?

Age band ratingsComposite rate

What is your rate?

16. Flexible Benefits (Cafeteria) Plan

Do you offer Section 125 flexible benefits (also known as a Cafeteria Plan) to your employees?

YesNo

Which of the following flexible benefits do you offer employees? Select all that apply.

Section 125 Benefits Offerings

Medical, Dental, and Vision Premiums

% of Eligible Employees Participating

FSA: Medical Care Spending Acct.

SEPARATOR: FSA MED CARE

% of Eligible Employees Participating

Contribution Limits and Participation

Annual Maximum

Participant Average

FSA: Dependent Care Spending Care Acct.

SEPARATOR: FSA DEP CARE

% of Eligible Employees Participating

Contribution Limits and Participation

Annual Maximum

Participant Average

HRA: Health Reimbursement Acct.

SEPARATOR: HRA

% of Eligible Employees Participating

Contribution Limits and Participation

Annual Maximum

Participant Average

Other

SEPARATOR: OTHER

What other benefits are offered to employees?

% of Eligible Employees Participating

Contribution Limits and Participation

Annual Maximum

Participant Average

Do you offer a plan in which participants are provided flexible dollars (or flexible credits) to allocate among various benefits, including a cash option?

YesNo

What is the average monthly flexible dollar amount per employee?

17. Pay Instead of Benefits

May employees opt to receive additional pay instead of benefits?

YesNo

What is your organization’s policy?

18. Tuition Reimbursement

Do you offer a tuition reimbursement program for employees?

YesNo

Are there eligibility requirements for employee tuition reimbursement?

YesNo

Required number of hours per week to qualify

Length of service required to qualify (in months)

What is the maximum dollar amount per year per employee?

Must courses be job related?

YesNo

Must courses be part of a degree program?

YesNo

Page 4

19. Retirement/Savings Plans

Do you offer formal retirement/savings plans to your employees?

YesNo

For the 401(k) or 403(b), is there a company matching contribution?

YesNo

What is your formula for company matching (e.g. 50% up to 5% of salary)?

For the 401(k) or 403(b), are participants allowed to direct their investments?

YesNo

How many investments choices are available to participants?

What is the vesting schedule for the plan(s)?

For Cliff vesting with 100% vesting, after how many years?

Elaborate on the vesting schedule for the plan.

Which of the following provisions are included in the plan(s)?

Participant loansHardship withdrawalsIn-service withdrawals

21. Cobra Administration

Who handles your COBRA administration?

Employer (handled in-house)Third-Party AdministrationInsurance Carrier

22. Benefits for Retirees

Do you provide retiree benefits to any of your employees (hourly, salaried, management or executives)?

YesNo

Based on their employment classification, what benefits do you provide for your retirees?

Please describe the other benefits you provide to your retirees.

23. Communication of Benefits

Do you use web-based technology to communicate benefits information to your employees?

YesNo, but we plan to within the next 1-2 yearsNo, and we have no plans to do so in the near future

24. Cost of Benefits

SEPARATOR: Calculations for cost of benefits

Do you know your organization’s cost of employee benefits (both including and excluding paid time off) as a percentage of the company’s overall payroll? (If you do not, you will complete a table below that will automatically calculate it based on your organization’s gross payroll and expense of PTO, non-mandatory benefits and mandatory benefits.)

YesNo

Cost of employee benefits (excluding paid time off) as a % of the company’s overall payroll

Cost of employee benefits (including paid time off) as a % of the company’s overall payroll

To calculate the cost of benefits, please complete the following fields. Your cost of benefits as a percentage of the company’s overall payroll will automatically calculate based on the information you input.

Total annual expense of all non-mandatory benefits (anything offered in your benefits package, including health, dental, vision, tuition reimbursement, miscellaneous benefits, etc. but excluding the cost of paid time off benefits)

Total annual expense of mandatory benefits (FICA, SUTA, etc.)

Total annual expense of all non-mandatory AND mandatory benefits

Annual gross payroll for all employees

Estimated annual expense of paid time off (vacation, sick leave, etc.)

Cost of employee benefits (excluding paid time off) as a % of the company’s overall payroll

Total mandatory and non-mandatory benefits plus annual expense of PTO

Cost of employee benefits (including paid time off) as a % of the company’s overall payroll

24. Miscellaneous Benefits

Please indicate which benefits you offer your employees, based on the following three employment classifications:

All Employees (includes management and executives)
Management (only includes management personnel)
Executives Only (only includes top-level executives)

Do you offer any work schedule or transportation benefits (e.g. work from home, free parking, etc.) to employees in any of the three classifications listed above?

YesNo

Work Scheduling/Transportation

	All Employees	Management	Execs Only
Flexible hours
Compressed work week
Job sharing
Telecommuting (work from home)
Bus vouchers
Free carpools/vanpools
Carpool/vanpool referrals
Free parking
Subsidized parking
Automobile mileage reimbursement
Automobile allowance/expense
Other

Please describe the other scheduling/transportation benefits you offer to employees.

Do you offer any financial or legal services benefits (e.g. relocation assistance, legal counseling, etc.) to employees in any of the three classifications listed above?

YesNo

Financial/Legal Services

	All Employees	Management	Execs Only
Free legal counseling
Subsidized legal counseling
Free financial counseling
Subsidized financial counseling
Free tax assistance
Subsidized tax assistance
Free pre-retirement counseling
Subsidized pre-retirement counseling
Credit union membership
Interest-free/low-interest loans
Moving and relocation assistance
Mortgage subsidy program
Adoption assistance
College fund program (529)
Other

Please describe the other financial/legal services benefits you offer to employees.

Do you offer any health or wellness benefits (e.g. free flu shots, stress management programs, etc.) to employees in any of the three classifications listed above?

YesNo

Health/Wellness

	All Employees	Management	Execs Only
Employee assistance program
Time/stress management programs
On-site fitness facilities
Free health club memberships
Subsidized health club memberships
Self-defense training
Free health screenings
Free flu shots
Blood bank accounts
Weight loss programs
Smoking cessation programs
Other

Please describe the other health/wellness benefits you offer to employees.

Do you offer any family care benefits (e.g. child care, elder care, etc.) to employees in any of the three classifications listed above?

YesNo

Family Care

	All Employees	Management	Execs Only
Child care referral services
On- or near-site child care facilities
Subsidized child care or vouchers
Free child care
Lactation program
Elder care referral services
Elder care financial assistance
Other

Please describe the other family care benefits you offer to employees.

Do you offer any special recognition awards (in the form of cash, trips, etc.) to employees in any of the three classifications listed above?

YesNo

Special Recognition Awards (in the form of cash, trips, etc.) for:

	All Employees	Management	Execs Only
Attendance
Length of service
Employee-of-the-month/year/etc.
Safety
Employee suggestions
Patents and innovative ideas
Sales
Other

Please describe the other special recognition awards you offer to employees.

Do you offer any additional benefits to employees?

YesNo

Other Benefits

	All Employees	Management	Execs Only
Discount on your products/services
Free meals
Subsidized meals
Free cell phone service
Subsidized cell phone service
Casual dress on certain days
Casual dress every day
Concierge services
Discounted tickets to movies, shows, etc.
Free tickets to movies, shows, etc.
Executive retreats
Company picnics and outings
Gift certificates
Charitable contributions on employee’s behalf
Sabbatical leave
Other

Please describe the other benefits you offer to employees.

Thank you for participating in this Employee Benefits Survey!

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Profit-Sharing	Profit-Sharing with 401(k)
401(k)	403(b)
457	Money Purchase
Defined Benefit	ESOP
Other

Immediate 100% vesting	5-year graded vesting
6-year graded vesting	7-year graded vesting
Cliff vesting with 100% vesting	Other

817.877.0014

info@whitneysmithco.com

Page 1

2. Paid Time Off

3. Vacation

4. Sick leave

5. Extended Illness Account

6. Holidays

Page 2

7. Personal Days

8. Other Paid Absences

9. Medical Leaves of Absence (FMLA and Parental)

Parental Leave (NOTE: THIS SUBSECTION IS NEW)

10. Personal/Educational Leaves of Absence

11. Medical Benefits

12. Dental Benefits

Page 3

13. Vision Care Benefits

14. Disability Benefits

15. Life Insurance

16. Flexible Benefits (Cafeteria) Plan

17. Pay Instead of Benefits

18. Tuition Reimbursement

Page 4

19. Retirement/Savings Plans

21. Cobra Administration

22. Benefits for Retirees

23. Communication of Benefits

24. Cost of Benefits

24. Miscellaneous Benefits

Thank you for participating in this Employee Benefits Survey!

(817)-877-0014