EMPLOYER QUESTIONNAIRE
*The purpose of this questionnaire is to find out more about your business and your current benefits package. The answers to the following questions are intended to uncover ways we may be able to assist you.*
Name of your company
Contact name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Company address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of full-time employees?
Number of part-time employees?
Number of 1099 employees?
Number of workplace locations?
Do you currently offer major medical insurance to your employees?
Yes
No
Name of health insurance carrier
Deductible amount (select all that apply, if you have more than one option)
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
Other
What percentage of premium does company pay toward employee only coverage?
What percentage of premium does company pay toward spouse/dependent coverage?
Percentage of employees who are enrolled in company health plan?
Renewal date for company health plan
-
Month
-
Day
Year
Date
Does company provide company-paid life insurance?
Yes
No
Amount of company-paid life insurance provided?
Name of carrier for company-paid life insurance?
Does company offer voluntary life insurance or buy-up option?
Yes
No
Name of carrier for voluntary life insurance (if different than carrier for company-paid life carrier)
Does the company offer dental insurance?
Yes
No
Name of dental insurance carrier
Back
Next
Percentage of dental insurance premium paid by the company
Does the company offer vision insurance?
Yes
No
Name of vision insurance carrier
Percentage of vision insurance premium paid by the company
Other benefits offered by the company.
Yes
No
Short Term Disability
Long Term Disability
Accident Policy
Hospital
Critical Illness
Cancer
Any of these benefits paid by the company?
Short Term Disability
Long Term Disability
Accident Policy
Hospital
Critical Illness
Cancer
Other
Name of the carrier that offers voluntary benefits (disability, accident, hospital, critical illness, cancer)
Does the company administer the Work Opportunity Tax Credit?
Yes
No
What is your biggest challenge regarding your current benefit package?
How do you communicate the benefits that are being offered to the employees?
Any benefits that you do not offer but employees have requested?
Does your company use an enrollment platform?
Yes
No
Any issues with Workers’ Compensation? Substantial claims, rate increases?
Anything else you would like to discuss?
Submit
Should be Empty: