Annual Report Of Self-Insured Voluntary Plan Transactions Form - 2004
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2Annual Report of Self-Insured Voluntary Plan Transactions
As required by California Code of Regulations, title 22, section 3267-2
Amended
Voluntary Plan #: 99-
Report for Calendar Year:
Number of CA employees covered
at the end of the calendar year:
Company Name and Mailing Address
1.
Beginning VP Fund Balance as of December 31 …………………………………………………….
2.
Income received during calendar year:
A.
Employee contributions withheld ……….…….
B.
Employer contributions …………...………...….
Interest income from VP Fund …….…….…….
C.
(Bank deposits, investments, interest)
…..
D.
Other income:
(Indicate employer loan to plan, workers' compensation reimbursement, benefits reimbursed
by EDD, employee overpayment recovery, funds transferred from other VPs, etc.)
$0.00
E.
Total Income (2A, B, C, and D) ………………………….…..……..……………………………
3.
Expenses during calendar year:
A.
Third Party Administration Fees …….……..….
B.
Employer Internal Administrative Expense ….
VP Assessment paid to Department …………
C.
(line K on DE3D) if charged to Plan
D.
Other Authorized Expenses ……..……..…..…
(i.e., Security Premiums, IME, Appeals, etc.)
E.
Benefits paid - Disability ………………..……………
F.
Benefits paid - Paid Family Leave ………………..
$0.00
G.
Total Expenses (3A through 3F) ………………..……….………………………...…………….
$0.00
4.
Ending VP Fund Balance as of December 31. (Add 1 and 2E; subtract 3G) …….………………
5.
Location of VP Funds:
Commercial Account
Bank & Address:
Savings Account
Bank & Address:
Other (explain)
Bank & Address:
6.
Print Name
Title
Area Code & Telephone No.
Date
THIS REPORT IS DUE ON FEBRUARY 15 OF EACH YEAR.
See "Instructions for Completing Annual Report…" (2nd tab on Excel version) for directions on how to submit your completed report.
DE 2568V Rev. 20 (6-04) (INTERNET)
Page 1 of 2
CU
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