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** This list is a sample and will
vary based on the actual benefits offered. **
Employee Information
Employee Social Security Number
Employee ID
Employee Last Name
Employee First Name
Employee Middle Initial
Employee Street Address
Employee Box or Apartment Number
Employee City
Employee State
Employee Zip Code
Employee Job Number
Employee Job Description
Department Number
Department Name
Employee Birth Date
Employee Hire Date
Employee Gross Salary
Employee Hourly Rate
Job Class (Hourly or Salaried)
Payroll Frequency
Deduction Frequency
Health Insurance Information
Health Plan
Health Coverage
Employee Only
Employee and
One Dependent
Employee and
Two or More Dependents
Employee Annual Health Insurance Contribution
Employer Annual Health Insurance Contribution
Dental Benefits
Dental Plan
Dental Coverage
Employee Only
Employee and
One Dependent
Employee and
Two or More Dependents
Employee Annual Dental Insurance Contribution
Employer Annual Dental Insurance Contribution
Vision Benefits
Employee Annual Vision Benefit Plan Contribution
Employer Annual Vision Benefit Plan Contribution
Life Insurance Information
Basic Term Life Coverage Amount
Employer Annual Basic Term Life Insurance Contribution
Supplemental Life Coverage Amount
Employee Annual Supplemental Life Insurance Contribution
Dependent Life Insurance Coverage Amount
Employee Annual Dependent Life Insurance Contribution
Long Term Care Insurance Information
Long Term Care Plan (Limited or Lifetime)
Long Term Care Coverage
Employee Only
Employee and
Spouse
Employee Long Term Care Benefit Amount
Spouse Long Term Care Benefit Amount
Employee Annual Long Term Care Insurance Contribution
Short Term Disability Insurance Information
Short Term Disability Benefit Amount
Employee Annual Short Term Disability Insurance Contribution
Employer Annual Short Term Disability Insurance Contribution
Long Term Disability Insurance Information
Long Term Disability Benefit Amount
Employee Annual Long Term Disability Insurance Contribution
Employer Annual Long Term Disability Insurance Contribution
Pension Information
Employee Annual Pension Contribution
Employer Annual Pension Contribution
Pension Date
Pension Years of Service
Dependent Care Flexible Spending Account
Employee Annual Dependent Care Flexible Spending Account Contribution
Medical Care Flexible Spending Account
Employee Annual Medical Care Flexible Spending Account Contribution
Other Benefits
Tuition Reimbursement
Parking
Health Clubs
Uniform Allowances
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