180-26 - Exhibit A. CDBG 2025 SPECS_compressed.pdf

5. The average weekly family leave insurance benefit during the one-year period, 6. The amount of sick leave, vacation leave or other fully paid time, which resulted in reduced benefit Duration during the one-year period, 7. With regard solely to family leave insurance benefit claims to care for sick family members, the amount of intermittent family leave insurance benefits paid during the one-year period, and 8. The average duration of family leave insurance benefits, in days, during the one-year period. The information reported in 1. through 8. above must be broken down by sex and by age group, beginning at 25 years and under and increasing in increments of 10. On or before the 30th day following the close of each calendar year during which a self-insured private plan for family leave insurance is in effect, the employer must file a report with the Division of Temporary Disability Insurance showing: 1. The amount of funds available at the beginning of that year for payment of family leave insurance benefits, 2. The amount contributed by workers during that year, 3. The direct cost of administration of the plan during that year, 4. The number of employees covered by the plan as of December 31, and 5. Such other information as the Division of Temporary Disability Insurance may require with respect to the financial ability of the self-insurer to meet the self-insured’s obligation under the plan. Workers’ Compensation Law (N.J.S.A. 34:15-1 et seq.) Upon the happening of an accident or the occurrence of any occupational disease, an employer who has insurance coverage or utilizes a third-party administrator shall promptly furnish the insurance carrier or the third-party administrator with accident or occupational disease information. Within three weeks after an accident or upon knowledge of the occurrence of an occupational disease, every insurance carrier, third-party administrator, statutory non-insured employer, including the State, counties, municipalities and school districts, and duly authorized self-insured employer not utilizing a third-party administrator must file a report designated as “first notice of accident” in electronic data interchange media with the Division of Workers’ Compensation through the Compensation Rating and Inspection Bureau in a format prescribed by the Compensation Rating and Inspection Bureau. When filed by an

change media with the Division of Workers’ Compensation through the Compensation Rating and Inspection Bureau in a format prescribed by the Compensation Rating and Inspection Bureau. When filed by an insurance carrier or third-party administrator, the report must also be sent to the employer. If the employer disagrees with the report, the employer may prepare and sign an amended report and file the amended report with the insurance carrier or third-party administrator. The amended report must then be filed electronically with the Division through the Compensation Rating and Inspection Bureau. MW-400 (11-11) Page 5 of 6