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["SUMMARY DATA - 20XX"]
[null,null,"# Of Claims Received","# of Claims Approved","# of Covered Employees","Administrative Costs","Employee Contributions","Amt of FL Funds Available","Intermittent FL Benefits Paid on Care Claims"]
[]
[]
["FL PP#","Name"]
[]
[]
["Number of Workers Receiving Benefits"]
[null,"FL PP#","Name","Bonding by Biological Parent with Newborn","Bonding by Domestic Partner","Bonding with Adopted","Care of Sick Child","Care of Sick Spouse","Care of Domestic Partner","Care of Sick Parent","Other Blood or Affinity Relationships","Total"]
[]
["Care Giver Male (age)"]
["25 and under",null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(D12:K12)","v":0}]
["26-35",null,null,null,null,null,null,null,null,null,null,0]
["36-45",null,null,null,null,null,null,null,null,null,null,0]
["46-55",null,null,null,null,null,null,null,null,null,null,0]
["56-65",null,null,null,null,null,null,null,null,null,null,0]
["66 and over",null,null,null,null,null,null,null,null,null,null,0]
["Total Male",null,null,{"$f":"SUM(D12:D17)","v":0},{"$f":"SUM(E12:E17)","v":0},0,0,0,0,0,0,0]
["Care Giver Female (age)"]
["25 and under",null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(D20:K20)","v":0}]
["26-35",null,null,null,null,null,null,null,null,null,null,0]
["36-45",null,null,null,null,null,null,null,null,null,null,0]
["46-55",null,null,null,null,null,null,null,null,null,null,0]
["56-65",null,null,null,null,null,null,null,null,null,null,0]
["66 and over",null,null,null,null,null,null,null,null,null,null,0]
["Total Female",null,null,{"$f":"SUM(D20:D25)","v":0},{"$f":"SUM(E20:E25)","v":0},0,0,0,0,0,0,0]
["Total (Male and Female)",null,null,{"$f":"SUM(D18,D26)","v":0},{"$f":"SUM(E18,E26)","v":0},0,0,0,0,0,0,0]
[]
["Amount of Benefits Paid"]
[null,"FL PP#","Name","Bonding by Biological Parent with Newborn","Bonding by Domestic Partner","Bonding with Adopted","Care of Sick Child","Care of Sick Spouse","Care of Domestic Partner","Care of Sick Parent","Other Blood or Affinity Relationships","Total"]
[]
["Care Giver Male (age)"]
["25 and under",null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(D33:K33)","v":0}]
["26-35",null,null,null,null,null,null,null,null,null,null,0]
["36-45",null,null,null,null,null,null,null,null,null,null,0]
["46-55",null,null,null,null,null,null,null,null,null,null,0]
["56-65",null,null,null,null,null,null,null,null,null,null,0]
["66 and over",null,null,null,null,null,null,null,null,null,null,0]
["Total Male",null,null,{"$f":"SUM(D33:D38)","v":0},{"$f":"SUM(E33:E38)","v":0},0,0,0,0,0,0,0]
["Care Giver Female (age)"]
["25 and under",null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(D41:K41)","v":0}]
["26-35",null,null,null,null,null,null,null,null,null,null,0]
["36-45",null,null,null,null,null,null,null,null,null,null,0]
["46-55",null,null,null,null,null,null,null,null,null,null,0]
["56-65",null,null,null,null,null,null,null,null,null,null,0]
["66 and over",null,null,null,null,null,null,null,null,null,null,0]
["Total Female",null,null,{"$f":"SUM(D41:D46)","v":0},{"$f":"SUM(E41:E46)","v":0},0,0,0,0,0,0,{"$f":"SUM(L41:L46)","v":0}]
["Total(Male and Female)",null,null,{"$f":"SUM(D39,D47)","v":0},{"$f":"SUM(E39,E47)","v":0},0,0,0,0,0,0,0]
[]
["Average Weekly Benefit Amount"]
[null,"FL PP#","Name","Bonding by Biological Parent with Newborn","Bonding by Domestic Partner","Bonding with Adopted","Care of Sick Child","Care of Sick Spouse","Care of Domestic Partner","Care of Sick Parent","Other Blood or Affinity Relationships"]
[]
["Care Giver Male (age)"]
["25 and under"]
["26-35"]
["36-45"]
["46-55"]
["56-65"]
["66 and over"]
["Care Giver Female (age)"]
["25 and under"]
["26-35"]
["36-45"]
["46-55"]
["56-65"]
["66 and over"]
["Average (Male and Female)",null,null,{"$f":"AVERAGE(D54:D66)","v":{"$error":"#DIV/0!"}},{"$error":"#DIV/0!"},{"$error":"#DIV/0!"},{"$error":"#DIV/0!"},{"$error":"#DIV/0!"},{"$error":"#DIV/0!"},{"$error":"#DIV/0!"},{"$error":"#DIV/0!"}]
[]
["Average Duration of Benefits (in days)"]
[null,"FL PP#","Name","Bonding by Biological Parent with Newborn","Bonding by Domestic Partner","Bonding with Adopted","Care of Sick Child","Care of Sick Spouse","Care of Domestic Partner","Care of Sick Parent","Other Blood or Affinity Relationships"]
[]
["Care Giver Male (age)"]
["25 and under"]
["26-35"]
["36-45"]
["46-55"]
["56-65"]
["66 and over"]
["Care Giver Female (age)"]
["25 and under"]
["26-35"]
["36-45"]
["46-55"]
["56-65"]
["66 and over"]
["Average all Male and Female",null,null,{"$f":"AVERAGE(D73:D85)","v":{"$error":"#DIV/0!"}},{"$error":"#DIV/0!"},{"$error":"#DIV/0!"},{"$error":"#DIV/0!"},{"$error":"#DIV/0!"},{"$error":"#DIV/0!"},{"$error":"#DIV/0!"},{"$error":"#DIV/0!"}]
[]
["Employer Required Paid Time Off Resulting in Reduced Benefit Duration"]
[null,"FL PP#","Name","Bonding by Biological Parent with Newborn","Bonding by Domestic Partner","Bonding with Adopted","Care of Sick Child","Care of Sick Spouse","Care of Domestic Partner","Care of Sick Parent","Other Blood or Affinity Relationships","Total"]
[]
["Number of claims with reduced benefit duration",null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(D91:K91)","v":0}]
["Total number of days of fully paid leave which reduced benefit duration",null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(D92:K92)","v":0}]
[]
["If you fail to remit a response to this request for this information, the self-insured private plan may be withdrawn and/or a $250 penalty for noncompliance may be issued to your account.  REQUIRED by N.J.A.C. 12:21-2.29(a), 2.30(a), 2.31(a)"]
[]
[]
[null,null,"Reports are due on or before the 30th day following the end of the calendar year. "]
[null,null,null,null,"Send to:"]
[null,null,null,null,"TDIECU@dol.nj.gov"]
[null,null,null,null,"OR"]
[null,null,null,"Attention:Supervisor"]
[null,null,null,"Private Plan Compliance Section"]
[null,null,null,"PO Box 957"]
[null,null,null,"Trenton, NJ 08625-0957"]
[]
[null,null,null,"FAX 609-292-2537",null,null,"Tel 609-292-2720"]