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Company Information
*Required Fields
*Company Name:
*First Name:
*Last Name:
*Address:
*City:
State:
WASHINGTON
*Zip Code:
*Work Phone:
Alternate Phone:
*Best time to contact:
*E-mail
Type of Company?
Do you currently have Business Group Health?
No
Yes
If yes, when does it renew?
Name of current carrier
Description of Business:
Number of Locations:
*Number of Employees:
2-5 employees
6-9 employees
10-19 employees
20-29 employees
30-49 employees
50 or more
Number of Employees currently covered:
Current Plan Information
Type of Health Plan:
--Select type--
HMO
POS
PPO
MSA / HSA / HRA
Not Sure
Current Deductible:
--Select amount---
$250
$500
$750
$1000
$1500
$2000
Other:
Current Co-Insurance
Percentage:
--Select from list---
90/10
80/20
70/30
60/40
50/50
Other:
Office Visit Co-pay?
No
Yes
If yes, co-pay amount
Prescription Drug (RX)
Co-pay?
No
Yes
If yes, co-pay amount
Dental Plan
in place?
No
Yes
Want Dental?
Yes
No
Vision Plan
in place?
No
Yes
Want Vision?
Yes
No
Section 125, Cafeteria or Premium Only Plan in place?
No
Yes
Voluntary Benefits (employee paid) in place?
No
Yes
Want Voluntary Benefits?
Yes
No
Employer Contribution Percentage for Employees?
--Select %---
50%
60%
70%
80%
90%
100%
Other:
Employer Contribution Percentage for Employee Dependants?
--Select %---
0%
50%
60%
70%
80%
90%
100%
Other:
Additional Comments or Questions?
Thank you for your inquiry!
Michael Benzikry & Associates, 9311 SE 36th Street #105, Mercer Island WA 98040 | Call (206) 232-1080
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