EMPLOYER GROUP INFORMATION
Multiple Locations *
PAYROLL INFORMATION
Payroll Frequency *
Payroll Deduction Frequency *
BENEFIT ADMINISTRATION
Integrated with Payroll? *
Currently Use Self Billing *
ENROLLMENT METHOD
How is Open Enrollment Conducted? *
Are New Hires Enrolled When Eligible? *
How are New Hires Enrolled *
EMPLOYEE BENEFITS CURRENTLY OFFERED
Please check "Yes" if the benefits below are currently offered. Otherwise, check "No". If you would like a proposal for a specific benefit please check "Request Proposal".
Basic life *
Voluntary/Supplemental life *
AD&D *
Whole life *
Basic short-term disability *
Voluntary short-term disability *
Basic long-term disability *
Voluntary long-term disability *
Critical illness *
Accident insurance *
Hospital indemnity *
Medical *
Dental *
Vision *
HRA *
HSA *
FSA *
Employee assistance plan *
VALUE ADDED SERVICES:
Which value added services would the group be interested in? *
ADDITIONAL NOTES: