Continuation during FMLA Does employee have continued coverage with paid premium during FMLA? (Yes/No) Reinstatement Choices: 6 months (Applicable to lay-off and Not Applicable of absence) Other (provide details) Reinstatement for Rehires Does reinstatement to rehired employees? (Yes/No) If Yes, is the reinstatement period the same time period? Earnings Definition See below for a description of the Earnings Definitions. For choices 6) or 7): What is (Please indicate the number included in the W2? and the details of the definition.) For choices 3), 4), or 7): What is the time period for Choices: averaging? 104 156 Standard weeks? Standard & Hourly Standard & Average For choices 3) or 4): What is Standard, Hourly & averaged and who does it Average apply to? Not Applicable Prior Year W2 Average W2 Other Earnings based on: Enter based on Earnings Definition. Note: Earnings definition may or may not always match the Choices: - Scheduled Hours Minimum Hours Requirement - Actual Hours Worked on Page 1 regarding Scheduled or Actual. "The Day" for the "Earnings Earnings Determination Determination". This means (determination date must be the same as the EARNINGS that the employee's benefit will be determined by CHANGE) his/her wages on the day just before the date of the loss. Choices: the date first of the month following Policy Anniversary Date Specific MM/DD Other (provide details) Premium Period Enter the Premium Grace Default: 60 days Period: 60 days (Default) EOI Approval Effective Date Required to match the Individual Effective Date on the plan. There are to be "No" variations.
Continuation during FMLA Does employee have continued coverage with paid premium during FMLA? (Yes/No) Reinstatement (Applicable to lay-off and of absence) Choices: 6 months Not Applicable Other (provide details) Reinstatement for Rehires Does reinstatement to rehired employees? (Yes/No) If Yes, is the reinstatement period the same time period? Earnings Definition For choices 6) or 7): What is included in the W2? For choices 3), 4), or 7): What is the time period for averaging? 104 156 weeks? For choices 3) or 4): What is averaged and who does it apply to? See below for a description of the Earnings Definitions. (Please indicate the number and the details of the definition.) Choices: Standard Standard & Hourly Standard & Average Standard, Hourly & Average Not Applicable Prior Year W2 Average W2 Other Earnings based on: Note: Earnings definition may or may not always match the Minimum Hours Requirement on Page 1 regarding Scheduled or Actual. Enter based on Earnings Definition. Choices: - Scheduled Hours - Actual Hours Worked Earnings Determination (determination date must be the same as the EARNINGS CHANGE) "The Day" for the "Earnings Determination". This means that the employee's benefit will be determined by his/her wages on the day just before the date of the loss. Choices: the date first of the month following Policy Anniversary Date Specific MM/DD Other (provide details) Premium Period Enter the Premium Grace Period: 60 days (Default) Default: 60 days EOI Approval Effective Date Required to match the Individual Effective Date on the plan. There are to be "No" variations.