Prevailing Wage Fringe Approval Request Form

Select your language. (Optional)

Before you begin this form, please be sure that you have filled out the Fringe Benefit Spreadsheet

If you are on a self-insured/self-funded plan please fill out the Self Funded Fringe Benefit Spreadsheet



If the date in the title of your current fringes is over a year old, this is an annual approval. If you have completed an annual approval within the last year, and you just have minor changes to report, this is an update.








Company information

What is my EIN? Your company’s unique 9 digit federal tax ID number (XX-XXXXXXX). You can find your company’s EIN on previous tax returns, business bank account statements, or payroll documents.



Company Information

What is my EIN? Your company’s unique 9 digit federal tax ID number (XX-XXXXXXX). You can find your company’s EIN on previous tax returns, business bank account statements, or payroll documents.



Contact Information





  • Collective Bargaining Agreement (CBA)
  • Benefits Breakdown - The current fringe benefit breakdown, with effective dates. Provide a description of acronyms and what benefit they provide the employee.

Annual

Please select the benefits that you are claiming, and confirm that all required supporting documentation is included with your submission. Your fringe request will not enter the queue to review until all required supporting documents have been provided.

Health Insurance

Yes

How can I tell if my insurance is self-insured/self-funded? If your invoices list Admin or Fixed Costs separate from Claims-Funding or Variable Costs, your plan is self-insured. Self-funded medical plans split the insured’s monthly premium into fixed, and claims funding amounts. This information can be found on your health insurance provider’s itemized invoice, and/or plan information booklet. Please fill out and attach the self-funded benefits spreadsheet linked on page 1 of this form.

Self-Insured/Self-Funded Plans: Prevailing Wage policy approves a default of 100% of fixed/admin costs, 75% of variable or claims funding costs, minus employee contributions. Companies that are able to provide three years of historical utilization data may be approved for their actual utilization percentage rather than the 75%.


  1. Document or invoice from the third-party administrator showing the monthly premium equivalents broken down into fixed costs (admin) and variable costs (claims funding).
  2. Employee copremiums, if any.
  3. Current invoice listing claimed employees and what plan level and tier they chose.
  4. OPTIONAL: Three years of historical utilization data for the plan, showing estimated claims and actual claims. Absent three years of data, the plan will be approved at our default rate of 100% of fixed/admin costs, and 75% of variable or claims funding costs.


No

  1. The company’s benefit policy
  2. Explanation of the premium share for benefit: the amount (either flat rate or percentage) that the employee pays and the amount (either flat rate or percentage) that the company pays.
  3. Current insurance provider invoice that lists all claimed employees and the premiums paid.  

Dental Insurance

  1. The company’s benefit policy
  2. Explanation of the premium share for benefit: the amount (either flat rate or percentage) that the employee pays and the amount (either flat rate or percentage) that the company pays.
  3. Current insurance provider invoice that lists all claimed employees and the premiums paid.


Vision Insurance

  1. The company’s benefit policy
  2. Explanation of the premium share for benefit: the amount (either flat rate or percentage) that the employee pays and the amount (either flat rate or percentage) that the company pays.
  3. Current insurance provider invoice that lists all claimed employees and the premiums paid.  


Other Health and Welfare Insurance

  1. The company’s benefit policy
  2. Explanation of the premium share for benefit: the amount (either flat rate or percentage) that the employee pays and the amount (either flat rate or percentage) that the company pays.
  3. Current insurance provider invoice that lists all claimed employees and the premiums paid.  


Life or disability (STD/LTD) Insurance

    1. The company’s benefits policies.
    2. Explanation of the premium share for each benefit: the amount (either flat rate or percentage) that the employee pays and the amount (either flat rate or percentage) that the company pays.
    3. Current insurance provider invoice that lists all claimed employees and the premiums paid.
    4. If the insurance policy premiums are based on age, provide the ages of employees (NOT required)


    401(k)

    Benefit requirement: Only the company contributions can be approved, and contributions must be paid at least on a quarterly basis.)

    1. The company’s benefits policies.
    2. Current remittance report that lists all claimed employees and the company’s contributions


    Pension Plan

    Benefit requirement: Only the company contributions can be approved, and contributions must be paid at least on a quarterly basis.)

    1. The company’s benefits policies.
    2. Current remittance report that lists all claimed employees and the company’s contributions


    Vacation/PTO

    1. Company’s employee handbook or benefits policies.


    Sick

    1. Company’s employee handbook or benefits policies.


    Holiday

    1. Company’s employee handbook or benefits policies.


    TRAINING/APPRENTICESHIP PROGRAMS

    1.  Provide company policy.
    2.  Provide a **current invoice** that **lists all claimed employees**, tuition/fees paid, and frequency of payment (ex. monthly, quarterly, annual).


    UpdateS

    Health Insurance

    Yes

    How can I tell if my insurance is self-insured/self-funded? If your invoices list Admin or Fixed Costs separate from Claims-Funding or Variable Costs, your plan is self-insured. Self-funded medical plans split the insured’s monthly premium into fixed, and claims funding amounts. This information can be found on your health insurance provider’s itemized invoice, and/or plan information booklet. Please fill out and attach the self-funded benefits spreadsheet linked on page 1 of this form.

    Self-Insured/Self-Funded Plans: Prevailing Wage policy approves a default of 100% of fixed/admin costs, 75% of variable or claims funding costs, minus employee contributions. Companies that are able to provide three years of historical utilization data may be approved for their actual utilization percentage rather than the 75%.


    1. Document or invoice from the third-party administrator showing the monthly premium equivalents broken down into fixed costs (admin) and variable costs (claims funding).
    2. Employee copremiums, if any.
    3. Current invoice listing claimed employees and what plan level and tier they chose.
    4. OPTIONAL: Three years of historical utilization data for the plan, showing estimated claims and actual claims. Absent three years of data, the plan will be approved at our default rate of 100% of fixed/admin costs, and 75% of variable or claims funding costs.


    No

    1. The company’s benefit policy
    2. Explanation of the premium share for benefit: the amount (either flat rate or percentage) that the employee pays and the amount (either flat rate or percentage) that the company pays.
    3. Current insurance provider invoice that lists all claimed employees and the premiums paid.  

    BENEFITS SPREADSHEET

    We have found an existing approved annual benefits submission for you. Please check your records for the expiration date or contact us at PWFringes@denvergov.org. You may submit your next annual fringe benefits request within 30 days of expiration.

    You have submitted an update within the past 30 days. Please check your records to make sure that this is not a duplicate submission and try again after {'Most Recent Submission Date' + 30 days}.

    You cannot submit an update request if you have not done business with the City of Denver before. Please submit an annual request.

    Your most recent annual benefits selection is expired in our system. Please renew your annual benefits by selecting 'Annual' instead of 'Update' on this form.

    You already have an annual benefits submission on file. If you need to update your submission, please revisit this form in two weeks and submit an update to your current benefits submission or contact PWFringes@denvergov.org.

    You may not submit a fringe update if a fringe annual has not yet been approved by the City and County of Denver.

    Contact Information