Laserfiche WebLink
GGFM-ER-8514 Maxwell Health Employer Information Form 02/24 <br /> Long-term disability insurance <br />Sun Life plan .................................................................................................................................................... Yes No <br />If “Yes,” please fill in the portion of the premium cost that you, as the employer, will be contributing (if applicable). <br />If “No,” skip to “Non-Sun Life Plan Information: Long-term disability insurance” section. <br />A.Column A: If your plan has more than one employee class, specify the name of each class. If you need more room, <br />you may attach a separate sheet. If your plan has one class, use the first row and write, “All Eligible Employee.” <br />Column B: Specify who contributes to the cost of coverage <br />Column C: If shared contributions and the Employees portion is paid on a post-tax basis, the 3-Year Look-Back %* <br />is required. This information will decide the taxability of an Employees claim. The 3-Year Look-Back should be updated <br />on an annual basis. <br />* The "Three-Year Look-Back" rule a requirement of IRS Code Section 105. Please contact your Sun Life Financial Representative <br />for the Sun Life Financial White Paper titled the "Three-Year Look-Back Rule" for more information about determining the look-back <br />percentage. <br />A B C <br />Name of Class Premium Contributions <br />If shared <br />contributions paid <br />post-tax, provide <br />3-Year Look-Back % <br /> 100% Employer Paid <br /> Gross Up <br /> 100% Employee Paid <br /> pre-tax post-tax <br /> Shared Contributions Employee Paid % <br /> pre-tax post-tax (see Column C) <br /> % <br /> 100% Employer Paid <br /> Gross Up <br /> 100% Employee Paid <br /> pre-tax post-tax <br /> Shared Contributions Employee Paid % <br /> pre-tax post-tax (see Column C) <br /> % <br /> 100% Employer Paid <br /> Gross Up <br /> 100% Employee Paid <br /> pre-tax post-tax <br /> Shared Contributions Employee Paid % <br /> pre-tax post-tax (see Column C) <br /> % <br /> 100% Employer Paid <br /> Gross Up <br /> 100% Employee Paid <br /> pre-tax post-tax <br /> Shared Contributions Employee Paid % <br /> pre-tax post-tax (see Column C) <br /> % <br />Should this be pre-selected for eligible employees on a voluntary basis? ............................................ Yes ... No <br />If “Yes,” employers should provide clear instructions to their employees, letting them know that they will be automatically enrolled <br />and payroll deduction will be initiated unless the employee affirmatively declines coverage on the Maxwell Health benefits <br />administration platform. <br />Employers should also review their payroll deduction records, to ensure that employees who decline coverage have been deleted <br />from the bill before any payroll deductions are made. <br />Docusign Envelope ID: BA987120-63B9-40BD-A4CA-C6E248AD9B65 <br />City Council Members <br />X <br />X <br />All Appointive groups except <br />seasonal <br />X <br />X