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GGFM-ER-8514 Maxwell Health Employer Information Form 02/24 <br /> Contract and administrative options, continued <br />H.Definition of earnings: The amount of an employee’s earnings upon which claims will be paid, and upon which <br />premium amounts are calculated. PFML will be calculated based on statute. Choose the applicable definition from <br />the following list. <br /> Gross earnings (standard) –This includes employee pre-tax contributions to a qualified deferred compensation <br />plan, 401(k) plan, Section 125 plan, health savings account, or flexible spending account. These exclude <br />commissions, bonuses, overtime pay and extra compensation. <br />If “Gross earnings” was selected above, please make the appropriate selection below. If a selection is not made, <br />you will receive current gross earnings with salary changes taking place immediately. <br /> Current earnings (standard) – If current earnings, salary changes take effect (select one): <br /> Immediately (standard) 1st of the month following 1st of the month coincident with or next following <br /> Prior calendar year(s) earnings – salary changes take effect of January 1st <br /> Frozen earnings as of (example: June 1st) – salary changes will take place on the date selected <br />If gross earnings include shift differential, or any other extra compensation, please specify. Please indicate here if <br />earnings also include: <br />Averaged over: 12 months 24 months 36 months Prior <br />calendar year <br />Prior 2 <br />calendar years <br />Prior 3 <br />calendar years <br /> Commissions* <br /> Bonuses* <br /> Overtime Pay* <br />*Commissions bonuses, and/or overtime pay selected above are averaged together with earnings. If this should be <br />otherwise, please specify. <br />If the definition is not for all coverages / classes, this definition applies to: <br />_________________________________________________________________________________________ <br />W-2 earnings – These exclude employee pre-tax contributions to a qualified deferred compensation plan, 401(k) <br />plan, Section 125 plan, health savings account, or flexible spending account, but will include overtime pay, <br />commissions, bonuses and any other income that is reported on the employee’s W-2 as “salary, wages and tips.” <br />Averaged over: Prior calendar year Prior 2 calendar years Prior 3 calendar years <br /> If the definition is not for all coverages / classes, this definition applies to: <br />_________________________________________________________________________________________ <br />Salary changes for W-2 earnings take effect on January 1st <br /> Earnings for Partners, Owners, and/or Shareholders – If the earnings above will not apply to a partner, owner, <br />or shareholder, please complete the following questions. <br />Is your type of organization a Partnership (Form 1065 Schedule K-1)? .......................................... Yes No <br /> Ordinary Business Income Guaranteed payments <br /> Ordinary Business Income plus guaranteed payments Net earnings from self-employment <br />If you are a Healthcare Professional group, is the Schedule K-1 paid by the <br />Policyholder to the Physician’s own company? ................................................................ Yes No N/A <br />Is your type of organization an S Corporation (Form 1120S Schedule K-1)? .................................. Yes No <br /> Ordinary Business Income Ordinary Business Income with W-2 earnings <br />If you are a Healthcare Professional group, are earnings paid to the Shareholders <br />associated company? ....................................................................................................... Yes No N/A <br />Is your type of organization a Sole Proprietor (Form 1040 Schedule C Net Income)? .................... Yes No <br />Salary changes for Partners, Owners, and/or Shareholders earnings take effect on January 1st <br />Docusign Envelope ID: BA987120-63B9-40BD-A4CA-C6E248AD9B65 <br />X <br />X <br />X