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Benefits Administration Questionnaire
BENEFITS ADMINISTRATION QUESTIONNAIRE (1)
Step 1 of 3
33%
Agent / Agency Information
Agency / Producer Name
Company Data
Company Name / Identifier
First
Address
Street Address
Contact Phone
*
Email
*
Contact Name
First
Title
City/State/Zip
City
Type of Business / SIC Code
How did you hear about us? Select all that apply:
Email
LinkedIn
Online Search
Professional Association Event
Webinar
Employee Demographics
Number of Employees
Full-time
Part-time
Retirees
COBRA
Number of:
Unions
Locations
States
Comments
Medical Coverage
Do you have Medical Coverage?
Yes
No
Current Carrier
Renewal Date
Plan Type (PPO; HMO; Q-HDHP)
Total Annual Ded (EE / EE+) / Employees Exposure
Employer Funding (HSA, HRA, etc.)
Explaination of Funding
Co-Insurance Details
Out-of-Pocket Maximum
Urgent Care / Emergency Room Co-pay
Comments
Do you have Another Medical Coverage?
Yes
No
Current Carrier
Renewal Date
Plan Type (PPO; HMO; Q-HDHP)
Total Annual Ded (EE / EE+) / Employees Exposure
Employer Funding (HSA, HRA, etc.)
Explaination of Funding
Co-Insurance Details
Out-of-Pocket Maximum
Urgent Care / Emergency Room Co-pay
Comments
Do you have One Another Medical Coverage?
Yes
No
Current Carrier
Renewal Date
Plan Type (PPO; HMO; Q-HDHP)
Total Annual Ded (EE / EE+) / Employees Exposure
Employer Funding (HSA, HRA, etc.)
Explaination of Funding
Co-Insurance Details
Out-of-Pocket Maximum
Urgent Care / Emergency Room Co-pay
Comments
Dental
Do you have Dental Coverage?
Yes
No
Current Carrier
Number of Plans
Employer Paid or Voluntary
Vision
Do you have Vision?
Yes
No
Current Carrier
Number of Plans
Employer Paid or Voluntary
Short Term Disability
Do you have Short Term Disability?
Yes
No
Current Carrier
Plan Design
Maximum Benefit
Employer Paid or Voluntary
Long Term Disability
Do you have Long Term Disability?
Yes
No
Current Carrier
Plan Design
Maximum Benefit
Employer Paid or Voluntary
Life Insurance
Do you have Life Insurance?
Yes
No
Current Carrier
Plan Design (Class 1)
Plan Design (Class 2)
Buy-Up option available
Dependent Coverage
Employer Paid or Voluntary
Outsourced Administration
Payroll
Cobra
HRA
HSA
FSA
Additional Benefits
Type of Plan
Current Carrier
Renewal Date
Employer Paid or Voluntary
Coverage type/description
Voluntary Benefits (Select all that apply)
Accident
Disability
Cancer
Critical Illness
Medical Gap Plan
Whole Life
Term Life
Additional Information
Comment1
Comment2
About Us
Who We Work With
Brokers & Consultants
Employers
How We Can Help
Technology Services
Solutions
Case Studies
Demos
Blog and Articles
Will 2021 be YOUR year?
Request a Quote
Contact Us
Email us at
[email protected]
or call 717 517-7016