Page 21 - Kirstie Test BenSum

Benefits Eligibility
SUMMARY OF BENEFITS
20-34 Hrs/Wk RPT
35+ Hrs/Wk RFT
Form Required
Notes/Exceptions
Y
Y
403b Enrollment/ Beneficiary Form
EE's @ 20 hrs+ elig. to contribute
Y
Y
Nationwide Enrollment Form
Contributions begin upon completion of eligibility period
Y
Y
Direct Contact
EE Paid direct to Liberty Mutual
Y
Y
None Required
Pro-rated for PT EE's
Y
Y
Payroll Deduction and Delta Enrollment Form
100% EE paid
Y
Y
Direct Deposit Form
EE may request deposit into a max of 3 accounts
Y
Y
None Required
Administered by The Hartford
Y
Y
EMB Request
DR's notes to HR
N
Y
The Hartford Beneficiary Form/PPI
RFT’s ONLY
Y
Y
csONE Flex Enrollment Form
Medical Spending Account Dependent Care Spending Account
Y if req to wk
Y
N/A
Holiday Compensation Policy
Y @ 100% prem. (20- 29 hours)
Y @ 30 hours
Payroll Deduction & Cigna Forms
30+hr/wk EE's pay by payroll ded; 20-29 hr/wk EE's pay 100% of premium
N
Y
The Hartford Enrollment Form
RFT ONLY, VOL Benefit only available at open enrollment only
Y
Y
Payroll Deduction & DeltaVision Enrollment Form
100% EE paid
Y
Y
VST Request Form
See VST policy for accrual rates
Y
Y
VST Cash In Form
Only applies to Non-Exempt EE's
N
Y
Application
Quarterly Submission $2000/year max. up to $8000 lifetime max.
Benefit Name
403b EE Contributions 403b ER Contributions
Liberty Mutual Discount Auto/Home Insurance
Bereavement Leave Dental
Direct Deposit
The Hartford EAP EMB
Employer Paid Life/AD&D/LTD Insurance
csONE Flex Spending Plan (Section 125 plan)
Holidays – 11 Paid Cigna Medical
The Hartford Supp Life Insurance (VOL)
DeltaVision
Vacation/Sick Time
VST Cash In (Non-Exempt Staff Only)
Tuition Assistance
<20 Hrs/Wk
N N N
N N
Y
Y N N
N
Y if req to wk
N
N N
N N
N
Key to abbreviations in above chart:
EE - RFT - VST - LTD - EAP -
Employee
Regular Full-Time (employee) Vacation/Sick Time
Long Term Disability Employee Assistance Program
HR -
RPT -
EMB -
AD&D - Accidental Death and Dismemberment VOL - Voluntary
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Edits to Summary Of Benefits Needed?
Human Resources
Regular Part-Time (employee)
Extended Medical Benefit