Does your current benefit program include:
(check all that apply)
Life Insurance
Accidental Death & Dismemberment (AD&D)
Short Term Disability (STD)
(if yes please complete the following)
Is your STD through an Insurance Company or in house
Is your STD registered with Employment Insurance?
Yes No
Long Term Disability
Health
Pay Direct Drug Card
Vision - if yes what is the amount covered every two years
(in dollars)
Basic Dental - if yes what percentage is covered
%
Major Dental - percentage covered
Orthodontic - percentage covered
Employee Assistance
Wellness
Employee Legal Assistance
How would you classify your Health Benefit experience?
Excellent Good Fair Poor
How would you classify your Dental Benefit experience?
How many years have you been with your present carrier?
When was the last time an audit of your benefits program
was done by a third party(other than your present broker)?
Please tell us where you heard about our site:
Your Name:
Company Name:
Phone Number:
Email Address: