Group Health Benefits
Company Name
Name of Contact
First Name
Last Name
Phone Number of contact
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many employees does the company have (total)
How many part-time employees?
How many full-time employees?
How many locations does the company have?
If more than one location, which cities/ states
Does the company offer Benefits at this time?
Yes
No
Which Benefits do/ or wish to put in place? (Check all that apply)
Medical
Dental
Vision
Group Life
Short Term Disability
Long Term Disability
Work place benefits
Other
If you currently have benefits, when is the renewal date?
If you do not currently offer benefits, what is your anticipation date to bring benefits into the company?
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