39-G1 - City of Burleson (01-017859-00) Disability - Payments Report.xlsx

This is a Disability Payments Report from Symetra Life Insurance Company for the City of Burleson, Texas, documenting short-term disability (STD), long-term disability (LTD), and voluntary STD (VSTD) benefit payments made to City of Burleson employees from 2022 through January 2026. The report details individual claim transactions including claim numbers, coverage types, pay periods, payment dates, gross amounts, tax withholdings (Federal Income Tax, Social Security FICA, and Medicare FICA), and net payments to beneficiaries. The spreadsheet encompasses multiple disability claims across the City of Burleson's employee base, with benefit payments ranging from under $100 to over $20,000 per transaction. The document shows adjustments and reversals for certain claims, indicating claim corrections or reconciliations throughout the coverage period. Coverage includes City of Burleson-STD-Class 1 policies with numerous individual claims documented under policy holder number 01-017859-00.

The report reflects actual disability benefit disbursements under the City's existing ancillary insurance benefits program, which encompasses life, disability, employee assistance programs, health savings accounts, flexible spending accounts, health reimbursement arrangements, COBRA administration, and voluntary worksite products. Total gross payments documented in the report amount to approximately $515,851.34, with net payments to beneficiaries totaling $425,661.74 after accounting for federal income taxes ($6,030.47) and FICA taxes ($22,789.79). The data demonstrates ongoing claims management and benefit payment processing through the existing Symetra disability insurance carrier, supporting the City of Burleson's ancillary benefits program administration. This report serves as historical documentation of disability benefit payments relevant to the procurement of continued ancillary insurance benefits for the municipality.