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NJ-2440      Statement in Support of Exclusion for Amounts Received
 (10-03)
                       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                 All taxpayers will be required to file with their annual New 
                                                                      (g)
    N.J.A.C. 18:35-2.3 (e)); 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 year 1982. The employee uses 12 vacation days 
ance company to which premiums are paid by both employees             and 10 sick days in 1982 for which he receives his regular wage 
and employer or solely by the employer; or whether insurance          payment, regardless of the cause for his absence. The amounts 
coverage is provided by an employer’s self-insured plan for which     received by the employee in 1982 for the 12 vacation days and 
no insurance premiums are paid by the employees.                      10 sick days are subject to tax as wage and salary income to the 
(d) The exclusion from taxable gross income applies to payments       employee and the employer must also withhold Gross Income Tax 
required to be made to employees under the State-mandated             on such payments.
temporary disability benefit plan pursuant to the New Jersey             Company Y has a self-insured disability plan for its employees 
                                                                      ii.
Temporary Disability Law (N.J.S.A. 43:21-25, et seq.). Payments       who are absent from work because of accident or sickness. The 
which are excludable from taxable gross income include tempo-         plan is fully funded by the employer company and the employees 
rary disability benefit payments required to be made under the        make no contribution to the plan. Payment for the full amount of 
State Plan which is administered by the Bureau of State Plan          wages is made to disabled employees absent from work, on the 
Disability Benefits under the New Jersey Disability Law. Exclusion    eighth calendar day. Payment for the initial seven days to the cov-
from taxable gross income also includes payments required to be       ered employee is discretionary with the company employer under 
made to employees under a company’s private plan established          the plan. The amount received by the absent employee because 
pursuant to New Jersey law in lieu of the State Plan described in     of his disability is excludable from taxable gross income as health 
the preceding sentence and which has been approved by the Bu-         or accident insurance after the initial seven days of absence but is 
reau of Private Plan Disability Benefits, Division of Unemployment    subject to withholding tax. Any amount received by the employee 
Insurance and Disability Insurance.                                   as payment for the seven initial days is subject to tax as wage and 
(e) Where payment to employees under the health or accident           salary income to the employee and is also subject to withholding 
insurance plan is largely discretionary with the employer, such as    tax.
during the initial period (for example, first seven days), the exclu-     Employee C receives a payment in 1982 from the New Jersey 
                                                                      iii.
sion from taxable gross income does not apply. Such payments          Disability Benefit Fund during an absence from work because of 
to the employee are subject to tax as wages and salaries. In          temporary disability resulting from illness. Both the employee and 
order for a wage loss payment made under an accident or health        employer have contributed to the disability benefit fund. The total 
insurance plan to be excludable from taxable gross income, the        amount received by the employee from the New Jersey Disabil-
payment to the employee must have a requisite certainty under an      ity Benefit Fund is excludable from taxable gross income as a 
enforceable contractual obligation.                                   payment for health or accident insurance and is not subject to 
(f) Effective June 1, 1982, withholding of the Gross Income Tax       withholding tax.
shall be required on all payments of wages and salaries made              Employee D is absent from work in 1982 because of illness 
                                                                      iv.
to an employee by an employer. The withholding or the tax is          and receives from the X Insurance Company the full amount of his 
required even though such payments meet all the conditions for        wages during the period of his absence from work. The payment 
exclusion from taxable gross income as made through an accident       was made from a health or accident insurance policy to which 
or health insurance plan for personal injuries or sickness under      only the employer has contributed. The amounts received by the 
this section. The only exceptions for the withholding of tax shall be employee are excludable from taxable gross income as health or 
for the following:                                                    accident insurance and are not subject to withholding tax.






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