Group Benefits Submission
Business Name
*
Business Address
*
Phone 2
*
Group / Business Health Plan
FEIN / EIN
Type: Major medical, limited benefit, ACA, none
Would like: FSA, HSA, Flex plan?
Number of employees
Effective date of health insurance
How often do employees get paid? Monthly/biweekly/weekly
Payroll Company
Do you have more than 1 location?
Health concerns: price/coverage/service?
Administrative / HR contact
Section 125 plan? Do you pay a fee for services?
Do you have access to your plan documents?
How are benefits enrolled?
Supplemental Insurance Benefits
Gap plan: Yes / no
Disability: Yes / no
Accident: Yes / no
Chronic/Critical illness: Yes / no
Dental: Yes / no
Cancer: Yes / no
Vision: Yes / no
Medicare eligible: Yes / no
Benefit Bank
Vacation/Sick leave
401(k)
Wellness Programs
How are benefit programs decided on in your company?
How are enrollments communicated to employees?
Benefits asked for by employees, but not offering?
What would you NOT change about your benefits?
Who are your competitors?
What makes you stand out as far as benefits?
Who would your employees come to in financial distress?
Do feel like your company experiences an abnormal amount of Workers Compensation claims?
Do you used a third party administrator for premium deductions?
Are you a union, association, or PEO (Professional Employer Organization)
Do you have multiple locations to service?
Is separate billing required?
Who is the billing representative?
Billing representative contact (Name, phone, email)
What day of the week does payroll process?
File upload
Agent of record (who is your agent? or no one)
*
How did you find us?
*
Referral
Agent
TV
Website
LinkedIn
Facebook
Tiktok
Instagram
Other
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