Employer'S Quarterly Wage And Contribution C-101 Report Item-By-Item Instructions - Vermont Department Of Labor Page 3
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5Vermont Department of Labor
HEALTH CARE ASSESSMENT WORKSHEET for ________________
(Quarter/Year)
Beginning April 1, 2007, if you have 9 or more employees it will be necessary to determine if a Health Care
Assessment Contribution will be due for the reporting quarter. Quarterly Health Care contributions are
calculated by determining the number of “Full Time Equivalent” (FTE) “uncovered” employees who worked for
you during the reporting quarter, as defined below.
Hours in the reporting quarter shall NOT exceed 520 for EACH “uncovered” employee.
Uncovered Vermont Employee Count:
Total # hours worked
by uncovered employees
Section I
If you do NOT offer to pay any part of Health Care costs:
Enter the total number of hours worked for all employees you employed during
the reporting quarter on this line and proceed to “Calculations” section of this form.
___________
Section II
If you DO offer to pay some part of Health Care cost:
• Enter the total number of hours worked for all employees, who were offered
and are eligible for coverage, but elect not to accept the coverage and
have no other health care coverage.
___________
• Enter the total number of hours worked for all employees who are not eligible
for health care coverage offered by you., ie health care not available due to
pre-existing health condition, until completion of probation, or for temporary
employees.
___________
(Employees enrolled in your health care coverage plan, who are not actually covered under
such plan until a subsequent effective date of coverage, shall not be considered an uncovered
employee, provided such intervening period is no longer than six months. Do not include these
employees in your calculation of uncovered employees.)
Calculations:
A. Enter the grand total of hours worked for all “uncovered employees” indicated above:
___________
Line A
B. FTE = Divide figure indicated on line A by 520 and enter results here:
___________
(Round down to the nearest whole number where applicable. Example: 9.75 would be 9.)
Line B
C. Subtract 8* from line B and enter results here. This is the number of “uncovered” FTE for
Health Care reporting purposes.
___________
(*8 is the number of exempt FTEs through June 30, 2008)
Line C
D. Multiply line C by $91.25 and enter the results here. This is your quarterly Health
Care Contribution.
___________
Line D
HC-1 (2/07)
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