How To Calculate Disability Benefits

Transcription

1 HRD (TDI)-3 Rev. 2/00 Dept: Payroll #: WORKSHEET FOR PROCESSING TD BENEFIT CLAIM (not applicable to employees on 56-hour workweek) Claimant s Name: Class Title: BU Code: SR / WB: SSN: A: FIRST CLAIM IN CALENDAR YEAR 1. Sick Leave Computation (SLC) a. Number of hours normally worked per week: hours b. Applicable Duration of TD Benefits table: Table: c. SLC Computation: (1) Sick leave hours used from first day of current calendar year to day preceding current disability: hours PLUS (2) Sick leave hours earned but not used as of first day of current disability (sick leave balance): hours (3) SLC (in hours): SLC = hours If SLC provides sick leave coverage for a total of three weeks or more, the employee is not entitled to TD benefits for the calendar year and no further computation is required. However, the employee should be notified that the claim is being denied in accordance with the procedure on Denial of Claim contained in Section M of the Plan. 2. Duration of Benefits In the applicable Duration of TD Benefits table, locate the employee s SLC under the column entitled Sick Leave Computation and read across tot he column entitled Duration of TD Benefits. Record the applicable data below. Duration of TD Benefits = weeks

2 Page 2. (Part A Worksheet) 3. Amount of Weekly TD Benefit Payment a. Compute employee s average weekly wage (AWW) by completing (1) or (2) below: (1) Salaried Employee with No Other Form of Remuneration monthly salary x 12 months 52 weeks $ x $ (2) Hourly Paid or Salaried Employee with Other Forms of Remuneration 8 weeks gross pay (or portion thereof) 8 week (or portion thereof) 8 $ b. The amount of the weekly TD benefits payment is based on (1) 58% of the employee s average weekly wages (AWW) or (2) the maximum weekly benefit amount (MWBA) as annually established by Labor Department whichever is less. (1).58 x AWW ($ ) = $ * (2) MWBA as annually established by Labor Department = $ (3) Amount of weekly TD benefit payment is lesser or (1) or (2) above Weekly TD Pay = $ * (The product of.58 x AWW, if not a multiple of $1, shall be rounded off to the next higher multiple of $1) 4. First day of disability is: 5. Date seven calendar day waiting period will end: a. Sick leave will be charged on the following working days of the waiting period: b. Approved vacation leave and/or compensatory time off will be charged on the following working days of the waiting period:

3 Page 3. (Part A Worksheet) 6. Date TD benefit payment will begin (accumulated sick leave credits must be used before benefit payment are allowed): 7. Date TD benefit payment will end (start from date shown in A,6 and extend that date by the figure shown in A,2,): 8. Date employee actually returned to work to perform usual duties: 9. Computation of MAXIMUM TD benefit payment for current disability: a. Duration of TD benefits (see A,2 above) weeks b. Amount of weekly TD benefit payment (see A,3,b,(3) above) $ c. MAXIMUM TD benefit payment for current disability $ 10. Computation of ACTUAL TD benefit payment for current disability: a. Actual duration of disability subject to TD benefit payment (from date shown in A,6 to the earlier date shown in A,7 or the day prior to A,8 above) weeks b. Amount of weekly TD benefit payment (see A,3,b,(3) above) $ c. ACTUAL TD benefit payment for current disability: $ CERTIFICATION: This is to certify that the employee is entitled to $ in temporary disability benefits for the period to. Date

4 Page 4. (Part B Worksheet) B. OTHER THAN FIRST CLAIM IN CALENDAR YEAR 1. Sick Leave Computation (SLC) a. Number of hours normally worked per week: hours b. Applicable Duration of TD Benefits table: Table: c. SLC Computation: (1) Sick leave hours used from first day of current calendar year to day preceding current disability: hours PLUS (2) Sick leave hours earned but not used as of first day of current disability (sick leave balance): hours (3) SLC (in hours): SLC = hours If SLC provides sick leave coverage for a total of three weeks or more, the employee is not entitled to TD benefits for the calendar year and no further computation is required. However, the employee should be notified that the claim is being denied in accordance with the procedure on Denial of Claim contained in Section M of the Plan. 2. Duration of Benefits In the applicable Duration of TD Benefits table, locate the employee s SLC for the current disability under the column entitled Sick Leave Computation and read across to the column entitled Duration of TD Benefits. Subtract the duration of TD benefits actually used or received for previous claim(s) in the same calendar year from the duration of TD benefits for the current claim as shown below: a. Duration of TD benefits for current claim: weeks MINUS b. Duration of TD benefits actually used or received for previous claim(s) in the same calendar year: weeks c. Net duration of TD benefits for current claim (if b is greater than a, enter zero): Net Duration of TD Benefits = weeks

5 Page 5. (Part B Worksheet) 3. Amount of Weekly TD Benefit Payment a. Compute employee s average weekly wage (AWW) by completing (1) or (2) below: (1) Salaried Employee with No Other Form of Remuneration monthly salary x 12 months 52 weeks $ x $ (2) Hourly Paid or Salaried Employee with Other Forms of Remuneration 8 weeks gross pay (or portion thereof) 8 weeks (or portion thereof) $ b. The amount of the weekly TD benefits payment is based on (1) 58% of the employee s average weekly wages (AWW) or (2) the maximum weekly benefit amount (MWBA) as annually established by Labor Department whichever is less. (1).58 x AWW ($ ) = $ * (2) MWBA as annually established by Labor Department = $ (3) Amount of weekly TD benefit payment is lesser of (1) or (2) above Weekly TD Pay = $ * (The product of.58 x AWW, if not a multiple of $1, shall be rounded off to the next higher multiple of $1) 4. First day of disability is: 5. Date seven calendar day waiting period will end: a. Sick leave will be charged on the following working days of the waiting period: b. Approved vacation leave and/or compensatory time off will be charged on the following working days of the waiting period:

6 Page 6. (Part B Worksheet) 6. Date TD benefit payment will begin (accumulated sick leave credits must be used before benefit payments are allowed): 7. Date TD benefit payment will end (start from date shown in B,6 and extend that date by the figure shown in B,2,c): 8. Date employee actually returned to work to perform usual duties: 9. Computation of MAXIMUM TD benefit payment for current disability: a. Duration of TD benefits (see B,2 above) weeks b. Amount of weekly TD benefit payment (see B,3,b,(3) above) $ c. MAXIMUM TD benefit payment for current disability $ 10. Computation of ACTUAL TD benefit payment for current disability: a. Actual duration of disability subject to TD benefit payment (from date shown in B,6 to the earlier date shown in B,7 or the day prior to A,8 above) weeks b. Amount of weekly TD benefit payment (see B,3,b,(3) above) $ c. ACTUAL TD benefit payment for current disability: $