| Business Name Address |
| City State Zip |
| Phone Email Website |
| Are you Self-Employed (Y/N) Do you have Employees (Y/N) |
| How Many Employees work for your Business? # Part-Time # Full-Time |
| Do you offer Medical Benefits to your Full-Time Employees? (Y/N) |
| Do you offer Medical Benefits to your Part-Time Employees? (Y/N) |
| If "YES", which company carries your Benefit Policy? (Blue Cross, etc.) |
| Are you "Self Insured" (Y/N) Human Resources Manager |
| When is your next "Open Enrollment" Schedule? From to |
CURRENT MONTHLY CONTRIBUTIONS FOR YOUR PRESENT BENEFIT PLAN
|
SINGLE EMPLOYEE
Total Premium $ Employer Contribution $ Employee Contribution $ |
DOUBLE (EMPLOYEE & SPOUSE)
Total Premium $ Employer Contribution $ Employee Contribution $ |
EMPLOYEE WITH FAMILY & CHILDREN
Total Premium $ Employer Contribution $ Employee Contribution $ |
DETAILS OF CURRENT MAJOR MEDICAL PLAN
|
Amount of Deductible $ Managed Care Co-Payment 80/20 70/30
|
| Do you offer DENTAL? (Y/N) Provider
[SINGLE] Total Premium $ Employer Contribution $ Employee Contribution $
[COUPLE] Total Premium $ Employer Contribution $ Employee Contribution $
[FAMILY] Total Premium $ Employer Contribution $ Employee Contribution $
|
| Do you offer VISION? (Y/N) Provider
[SINGLE] Total Premium $ Employer Contribution $ Employee Contribution $
[COUPLE] Total Premium $ Employer Contribution $ Employee Contribution $
[FAMILY] Total Premium $ Employer Contribution $ Employee Contribution $
|
Do you offer CHIROPRACTIC? (Y/N) Provider
[SINGLE] Total Premium $ Employer Contribution $ Employee Contribution $
[COUPLE] Total Premium $ Employer Contribution $ Employee Contribution $
[FAMILY] Total Premium $ Employer Contribution $ Employee Contribution $ |
Does your plan accept PRE-EXISTING CONDITIONS? (Y/N)
EXPLAIN (If Applicable)
|
| Business Contact Person |
| Business Contact Phone |
| Business Contact Email (if different from above) |
| PLEASE NOTE: All information collected in this survey remains confidential and will only be used for the sole purpose of conducting an analysis of your present Business expenses in providing Medical Benefits for your Employees. IAB's Benefit Specialist will in return submit a detailed report based on the completed information contained in this survey to the listed Contact Person in a timely manner, usually within 3 business days. This report is conducted on a complimentary basis and you are not under any obligation to accept or act upon any of the possible cost saving suggestions which may be rendered in the report. This Public Service Program is for educational purposes only. |
