Small Business Health Benefits Interest Survey
Name of Business
*
Tax ID Number
*
Business Owner/Authorizing Officer
*
First Name
Last Name
Does this business currently work with a broker that helps make decisions on health benefits?
*
Yes
No
If yes, please provide the broker's name
First Name
Last Name
Business Email Address
*
example@example.com
Company website
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employees
*
Rows
W-2
1099
Total
Number of Employees
When would you like your employee health benefits to start?
*
-
Month
-
Day
Year
Date
Number of Annual Payroll Deductions
*
Next Payroll Deduction Date
*
-
Month
-
Day
Year
Date
When will your employees be eligible for health benefits?
*
Immediately upon first day of employment
On the 90th day of employment
On the first day of the month following 90 days
What benefits would you be interested in offering your Employees?
*
Accident
Hospital Protection
Critical Care
Cancer Protection
Short Term Disability
Dental
Vision
Whole Life/Term Life
Universal Life
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: