Health Insurance

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If you do currently offer a group health plan to your employees, what types of coverage are available? (please check all that apply)





What types of coverage would you like in addition to primary medical? (please check all that apply)






Please indicate the total number of employees, including yourself, who are eligible for this group health insurance plan: [?]


- Please indicate the exact number: 
(Answer with numbers only, -- e.g., 4, not four.)

Do you currently offer group health insurance coverage?



Please provide the health plan & expiration date:

Please note: The number you enter should reflect only eligible employees and should not include any spouses or dependents.

What types of health insurance plans are you currently considering? (please check all that apply)





In which state(s) do you have employees residing?

(please list all states - ex. MA, MI, IL)

How many years has your company been in business?


How many eligible employees do you have within each of the following groups? [?]

Single employee(s)

Married/legally cohabitating - no children*

Single employee(s) with one or more children

Employees with families - spouse and one or more children*

Health plans with higher up-front, employee-paid, deductibles may also include lower premiums and greater flexibility. Do you have a preference for this type of plan? [?]




*Please note: States have varying definitions of what constitutes an "employee and spouse" relationship; please refer any questions regarding domestic partner eligibility to the suppliers that respond to your request.
*May result in higher premiums or co-insurance cost for employees
  Census: If 10 or fewer employees will be enrolled in the small business health insurance plan, please complete the following census for each employee, indicating sex, age, type of coverage needed and the employee's home zip code.

Please note: If you have greater than 10 employees, the vendor will be contacting you for the census information.

Sex Age Coverage Home Zip Code
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
 

What is the five digit ZIP code for your office location?

What is your e-mail address?

[?]

Please note any other considerations you would like suppliers to be aware of relating to your group health insurance inquiry:

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