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NJ-2440      Statement in Support of Exclusion for Amounts Received
 (6-22)
                       Under Accident and Health Insurance Plan
                         for Personal Injuries or Sickness

                             Year 

Employee:                                       Soc. Sec. No. 

Employer:                              I.D. No.

                             Periods of Sickness

             Number          Initial   Allowable Sick   Daily Rate  
 From     To Paid Days Minus Period    Days           x of Pay                                      = Sick Pay
                                                    x                                             =

                                                    x                                             =

                                                    x                                             =

                                                    x                                             =

                                                    x                                             =

                                                    x                                             =

                                                    x                                             =

                                                    x                                             =

                                                    x                                             =

                                                      Total Sick Pay For Year

This is to certify that the payment(s) set forth above meet all three criteria in N.J.A.C. 18:35-2.3

                                            Authorized Signature of Employer

                                            Title                                                      Date



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                                                 Gross Income Tax
                                    Employee Accident or Health Insurance Exclusion
                                                             N.J.A.C. 18:35-2.3
18:35-2.3   Employee accident or health insurance                         1.  Temporary disability benefit payments required to be 
    exclusion from taxable gross income                                   made under the State Plan which is administered by the 
                                                                          Bureau of State Plan Disability Benefits under the New 
(a) Amounts received by an employee through an accident or                Jersey Disability Law;
health insurance plan for personal injuries or sickness are not 
subject to tax under the New Jersey Gross Income Tax Act.                 2.  Temporary disability benefit payments required to be 
                                                                          made to employees under a company’s private plan 
(b) Amounts received by an employee on account of personal                established pursuant to New Jersey law in lieu of the 
injury or sickness qualify for exclusion from taxable gross income        State Plan described in (f)1 above and which has been 
when received under the provisions of an employee accident or             approved by the Bureau of Private Plan Disability Bene-
health insurance plan which satisfies the following requirements:         fits, Division of Unemployment Insurance and Disability 
    1.  The payments must be compensation for wage loss which             Insurance; and
    results from absence due to injury or sickness of the em-             3.  Payments made to employees for personal injuries or 
    ployee; and                                                           sickness under a health or accident insurance policy by a 
    2.  The payments must have a requisite certainty under an             commercial insurance company.
    enforceable contractual obligation under the plan (see (e)             All taxpayers will be required to file with their annual New 
                                                                      (g)
    below); and                                                       Jersey Gross Income Tax Return a claim form furnished by the 
    3.  The payments must not relate to sick leave wage contin-       Director for the exclusion of any amounts received by them as 
    uation, the taking of which is largely discretionary and the      an employee through an accident or health insurance plan for 
    payments are made regardless of the reason for absence            personal injuries or sickness which meet all the conditions for 
    from work.                                                        exclusion from taxable gross income under (f) 1, 2 and 3 above.
(c) The exclusion from taxable gross income applies to payments       Examples:
to employees under a health or accident insurance plan regard-           An employee of Company X is allowed 12 vacation days and 15 
                                                                      i.
less of whether insurance coverage is with a commercial insur-        sick days for the calendar year. The employee uses 12 vacation 
ance company to which premiums are paid by both employees             days and 10 sick days in the calendar year for which he or she 
and employer or solely by the employer; or whether insurance          receives his or her regular wage payment, regardless of the cause 
coverage is provided by an employer’s self-insured plan for which     for his or her absence. The amounts received by the employee 
no insurance premiums are paid by the employees.                      in the calendar year for the 12 vacation days and 10 sick days 
(d) The exclusion from taxable gross income applies to payments       are subject to tax as wage and salary income to the employee 
required to be made to employees under the State mandated tem-        and the employer must also withhold Gross Income Tax on such 
porary disability benefit plan pursuant to the New Jersey Tempo-      payments.
rary Disability Law (N.J.S.A. 43:21-25, et seq.). Payments which         Company Y has a self-insured disability plan for its employees 
                                                                      ii.
are excludable from taxable gross income include temporary            who are absent from work because of accident or sickness. The 
disability benefit payments required to be made under the State       plan is fully funded by the employer company and the employees 
Plan which is administered by the Bureau of State Plan Disability     make no contribution to the plan. Payment for the full amount of 
Benefits under the New Jersey Disability Law. Exclusion from tax-     wages is made to disabled employees absent from work, on the 
able gross income also includes payments required to be made to       eighth calendar day. Payment for the initial seven days to the 
employees under a company’s private plan established pursuant         covered employee is discretionary with the company employer 
to New Jersey law in lieu of the State Plan described in the pre-     under the plan. The amount received by the absent employee 
ceding sentence and which has been approved by the Bureau of          because of his or her disability is excludable from taxable gross 
Private Plan Disability Benefits, Division of Unemployment Insur-     income as health or accident insurance after the initial seven days 
ance and Disability Insurance.                                        of absence but is subject to withholding tax. Any amount received 
(e) Where payment to employees under the health or accident           by the employee as payment for the seven initial days is subject 
insurance plan is largely discretionary with the employer, such as    to tax as wage and salary income to the employee and is also 
during the initial period (for example, first seven days), the exclu- subject to withholding tax.
sion from taxable gross income does not apply. Such payments              Employee C receives a payment from the New Jersey Dis-
                                                                      iii.
to the employee are subject to tax as wages and salaries. In          ability Benefit Fund during an absence from work because of 
order for a wage loss payment made under an accident or health        temporary disability resulting from illness. Both the employee and 
insurance plan to be excludable from taxable gross income, the        employer have contributed to the disability benefit fund. The total 
payment to the employee must have a requisite certainty under an      amount received by the employee from the New Jersey Disabil-
enforceable contractual obligation.                                   ity Benefit Fund is excludable from taxable gross income as a 
(f) Withholding of the gross income tax shall be required on all      payment for health or accident insurance and is not subject to 
payments of wages and salaries made to an employee by an              withholding tax.
employer. The withholding of the tax is required even though such         Employee D is absent from work because of illness and 
                                                                      iv.
payments meet all the conditions for exclusion from taxable gross     receives from the X Insurance Company the full amount of his or 
income as made through an accident or health insurance plan for       her wages during the period of his or her absence from work. The 
personal injuries or sickness under this section. The only excep-     payment was made from a health or accident insurance policy to 
tions for the withholding of tax shall be for the following:          which only the employer has contributed. The amounts received 
                                                                      by the employee are excludable from taxable gross income as 
                                                                      health or accident insurance and are not subject to withholding 
                                                                      tax.






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