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Benefits Statement
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for: [Name of Employee]
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for the Year:
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(Formulas included)
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As an employee of [name of company[, you receive regular pay
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for the services you provide. The other part of your total
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compensation is the value of the benefits that [name of company]
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makes available to you and, if applicable, your family. The
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value of these benefits is your "hidden paycheck." This
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personalized benefits statement describes your hidden paycheck
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and is intended to give you a summary and the value of the
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benefits you personally receive. If you have any questions
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about this statement, please contact Human Resources.
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Employee Cost/Company Cost/
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ContributionContribution
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HEALTH & WELFARE BENEFITS
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Medical
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Dental
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Short-Term DisabilityN/A
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Long-Term DisabilityN/A
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Life InsuranceN/A
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Accidental Death & Disability (AD&D)N/A
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Employee Assistance Plan (EAP)N/A
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401(k) Plan
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Pension PlanN/A
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TOTAL HEALTH & WELFARE BENEFITS0٫00
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PAID LEAVE BENEFITS
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Vacation/Annual LeaveN/A
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Sick LeaveN/A
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Personal DaysN/A
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HolidaysN/A
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Other (Bereavement, Jury Duty, Military Leave)N/A
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TOTAL PAID LEAVE BENEFITS0٫00
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FEDERAL AND STATE-MANDATED BENEFITS
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Social Security
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Medicare
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Unemployment Insurance (Federal)N/A
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Unemployment Insurance (State)N/A
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Workers CompensationN/A
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TOTAL FEDERAL AND STATE-MANDATED BENEFITS0٫00
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OTHER BENEFITS
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Annual BonusN/A
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Flexible Spending Accounts (FSAs)--Pretax benefit
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(Amount of benefit related to individual tax bracket)
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TOTAL OTHER BENEFITS0٫00
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TOTAL VALUE OF EMPLOYER-PROVIDED BENEFITSN/A0٫00
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TOTAL COMPENSATION AND BENEFITS N/A
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(Annual Salary/Wages + Employer-Provided Benefits)
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